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[The significance of trandelapril for mortality after AMI in patients with reduced left ventricular function. TRACE
L Køber1, C T Torp-Pedersen, J E Carlsen
1Kardiologisk afdeling, Amtssygehuset i Gentofte.
Insights
Angiotensin converting-enzyme (ACE) inhibitors significantly reduce mortality in heart attack survivors with left ventricular dysfunction. Trandolapril use in these selected patients lowered overall death rates, supporting targeted ACE inhibition post-myocardial infarction.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Angiotensin converting-enzyme (ACE) inhibition is known to reduce mortality after acute myocardial infarction.
- The optimal strategy for ACE inhibitor use (universal vs. targeted) in post-myocardial infarction patients remains unclear.
Purpose of the Study:
- To evaluate the efficacy of long-term trandolapril treatment in reducing mortality in patients with left ventricular dysfunction following myocardial infarction.
Main Methods:
- A randomized, placebo-controlled trial involving 1,749 patients with echocardiographic signs of left ventricular dysfunction post-myocardial infarction.
- Patients received either oral trandolapril or a placebo, starting 3-7 days after infarction, with an average follow-up of 27 months.
Main Results:
- Trandolapril significantly reduced total mortality (34.7% vs. 42.3%, p=0.0013), with a relative risk of death of 0.78.
- The drug also decreased cardiovascular death, sudden death, and progression to severe heart failure.
- Recurrent myocardial infarction was not significantly reduced.
Conclusions:
- Long-term trandolapril treatment significantly reduces total mortality in patients with reduced left ventricular function after myocardial infarction.
- The observed mortality risk reduction in approximately 25% of screened patients suggests a benefit from selective ACE inhibition in this population.
Abstract:
Angiotensin converting-enzyme (ACE) inhibition reduces mortality among patients surviving an acute myocardial infarction, but whether to give ACE-inhibitors to all patients or target their use to selected patients is unclear. Seven thousand and one consecutive enzyme-confirmed myocardial infarctions were screened. One thousand seven hundred and forty-nine patients with echocardiographic signs of left ventricular dysfunction were randomized to oral trandolapril (876 patients) or placebo (873 patients) starting from days three to seven following the infarction. Average follow-up was 27 months. There were 304 deaths (34.7 percent) among patients on trandolapril vs. 369 deaths (42.3 percent) among patients on placebo (p = 0.0013). Relative risk (RR) of death in the trandolapril group was 0.78 (95% confidence interval (CD 0.67-0.91). Trandolapril reduced cardiovascular death (RR 0.75, CI 0.63-0.89) and sudden death (RR 0.76, CI 0.59-0.98). Progression to severe/resistant heart failure was reduced (RR 0.71, CI 0.56-0.90). Recurrent myocardial infarction (fatal or non-fatal) was not significantly reduced (RR 0.86, CI 0.66-1.13). It is concluded that long-term treatment with trandolapril in patients with reduced left ventricular function shortly after myocardial infarction significantly reduced total mortality. The substantial mortality risk reduction was obtained in 25% of consecutive patients screened for entry encouraging a selective use of ACE inhibition following myocardial infarction.