[Angiotensin-converting enzyme inhibitors in patients with preserved left ventricular function: from EUROPA to...

The trials with angiotensin-converting enzyme (ACE) inhibitors have followed a particular trend: in the first studies treatment was provided to severely ill patients several time (months or year) after the acute event. Thereafter, in few studies ACE-inhibitors were provided within 2 weeks of the event to patients with left ventricular dysfunction after acute myocardial infarction (AMI). In other megatrials ACE-inhibitors were started in unselected patients 24 hours after AMI. Thus, the trend is to provide treatment as early as possible to less selected patients. Recently, ACE-inhibitors have been successfully tested not only to treat the consequences of an infarct, but also to prevent its occurrence. EUROPA is the trial that demonstrated that perindopril (8 mg/day) is indicated in all coronary artery disease patients to reduce cardiovascular mortality and occurrence of AMI. The Perindopril and Remodelling in the Elderly with Acute Myocardial Infarction (PREAMI) is another trial recently terminated in elderly post-AMI patients with preserved left ventricular function. Although not associated with better clinical outcomes (most likely because of the rather short treatment period, 1 year), perindopril significantly reduced the combined primary endpoint (death, hospitalization for heart failure and remodeling) and prevented the progressive left ventricular remodeling occurring in elderly patients even in the presence of small infarct size.