This is the first visit to the site we rmend you read "".View by speciality MOST RECENT QUESTIONS: (Please click on a question for the answer) What is the evidence for using ACE long term post myocardial infact and do any particular types of infarcts respond better to ACE than others 25/Feb/08 ANSWER: The CKS guideline on the secondary prevention of myocardial infarction (MI) states: "For how long should drug treatment for secondary prevention after a myocardial infarction be continued?Inhibitors, aspirin, beta-blockers, and statins should be continued indefinitely in people who have had a myocardial infarction (MI): o However, some people may wish to review the benefits of long-term treatment.Requires a careful assessment and discussion of individual tolerance and preference, balanced against the magnitude of benefit in risk reduction.Risk reducing benefit is influenced by the level of individual risk and in some cases referral for specialist advice may be appropriate.Please note that, "This Topic Review does not cover the diagnosis of MI, or management immediately after an MI; nor does it cover the management ofplications of MI such as heart failure, post-infarction angina, and arrhythmias.Notes this rmendation is based on the NICE guideline on secondary prevention in primary and secondary care for patients following a myocardial infarction, issued last year.We consulted the full version of the NICE guideline, referred to above, to locate the following evidence to support the long-term use of ACE inhibitors post- MI."6.Effectiveness of long term ACE inhibitor therapy Patients with preserved left ventricular function A meta analysis of six randomised controlled trials in patients with stable coronary artery disease (CAD) and preserved left ventricular function found that treatment with an ACE inhibitorpared to placebo was associated with a reduction in cardiovascular mortality (RR 0.0.0.MI (RR 0.CI 0.0.(RR 0.CI 0.0.Coronary revascularisation rates (RR 0.CI 0.1.M.Et al 2006).Duration of follow up was 4.Range 2 to 4.The majority of patients were recruited to three large trials (Arnold, J.O.Al 2003) (Braunwald, E.Al 2004) (Fox, K.And EUROPA investigators 2003) in which 53%, 65% and 55% respectively had had a prior MI, at least one month earlier in one trial (Arnold, J.O.S.J.Al 2003) and at least three months in the other two trials (Braunwald, E.Al 2004) (Fox, K.And EUROPA investigators 2003).Patients with left ventricular systolic dysfunction.Review of long term trials of patients after MI with left ventricular systolic dysfunction identified 3 large trials which each recruited more than 1000 patients with a minimum follow up of one year.To treatment with an ACE inhibitor, initiated between 3 and 16 days after an acute MI, was associated with a reduction in mortality (OR 0.CI 0.0.For heart failure (OR 0.CI 0.0.Recurrent MI (OR 0.CI 0.0.Over a median follow up of 31 months (Flather, M.Et al 2000).The inclusion in the meta analysis of two randomised control trials of patients with reduced left ventricular systolic function, with (SOLVD Investigators 1991) or without (SOLVD Investigators 1992) symptoms of heart failure, the findings were similar.Five percent of patients in these other two trials had a previous history of MI._A 12 year follow up study of the SOLVD trials, in which 75% of participants had a previous MI (SOLVD Investigators 1991) (SOLVD Investigators 1992) found a reduction in all-cause mortality (OR 0.0.0.Cardiac deaths in those assigned for the duration of the trial to ACE inhibitor treatmentpared to those assigned to placebo (Jong, P.Al 2003).Result was consistent in both the prevention trial which recruited asymptomatic patients, and the treatment trial which recruited patients with symptomatic CHF.Up study of a randomised controlled trial which recruited patients with left ventricular systolic dysfunction 3 to 7 days after acute MI (Pfeffer, M.Braunwald, E.L.Et al 1992) found that at 12 years, patients who had been assigned to ACE inhibitor treatment during the original trial period for 2 to 4 years had a reduced risk of all-cause mortality (RR 0.CI 0.Hospitalisation (RR 0.CI 0.0.Cardiovascular hospitalisations (RR 0.CI 0.1.P.Al 2005).Controlled trials of the effectiveness of ACE inhibitor treatment in patients with chronic heart failure and left ventricular systolic dysfunction, which included patients with an MI in the past, is examined in The NICE guideline Chronic Heart Failure: national clinical guideline for diagnosis and management in primary and secondary care, 2003 (National Collaborating Centre for Chronic Conditions.These guidelines state that systematic reviews of randomised controlled trialsparing ACE inhibitor to placebo have found that ACE inhibitor therapy in patients with heart failure due to left ventricular systolic dysfunction increases life expectancypared to placebo.Effect is more marked in patients with more severe LV systolic impairment, or more severe symptoms, although there is benefit for all New York Heart Association functional classes (NYHA).Placebo, ACE inhibitor therapy also reduces the risk of hospitalisation for heart failure in such patients, and also for patients with asymptomatic left ventricular systolic dysfunction.We searched the Medline database for clinical trials published since the NICE guideline was published and found one study, published this month, reporting on the use of ACE inhibitors in patients with acute MI who were followed up for five years."_BACKGROUND: The causes of death occurring in clinical trials of myocardial infarction (MI) are scarcely reported in the literature.Analysis is aimed to describe the inhospital causes of death in patients with acute MI stratified to angiotensin converting enzyme (ACE) inhibitor treatment/no treatment, as described in the GISSI-3 trial.5-year survival analysis of GISSI-3 patients is reported.RESULTS: An independentmittee assigned the definition of causes of death of GISSI-3 based on clinical and/or anatomical data.Multivariable analyses were performed to identify the predictors of early and late deaths.Curves were used to describe the effects of ACE-I treatment on mortality on a median follow-up period of 56 months._Patients receiving lisinopril had fewer inhospital cardiac deaths than patients allocated to the no-lisinopril group (4.5.= .To a 12% relative risk reduction.Risk of dying from cardiac rupture was reduced by 39% by lisinopril treatment.In survival associated with the lisinopril treatment was mainly due to a reduction in cardiac rupture, electromechanical dissociation, and pump failure occurring early (within 4 days) from the onset of MI symptoms.Beneficial effects of lisinopril observed at 6 weeks (8 fewer deaths per 1000 treated patients) were maintained up to nearly 5 years (10 fewer deaths per 1000).Administration of ACE inhibitors in unselected patients with acute MI should be considered standard therapy to reduce early deaths, specifically those due to cardiac rupture.Early beneficial effect persisted up to nearly 5 years.Concerning whether patients with different types of infarcts respond better to ACE inhibitors than others, we found it difficult to search for specific types of infarcts as the medical databases use the general heading of myocardial infarction.Search using the subject heading with myocardial infarctionbined with ACE inhibitor found a systematic review of this drug treatment in patients with MI and chronic left ventricular dysfunction.Medline abstract of this study reads: "_BACKGROUND AND AIM: To summarize and quantify results of echocardiographic studies examining the effect of angiotensin converting enzyme (ACE) inhibition on left ventricular remodelling in patients with acute myocardial infarction (MI) and in patients with left ventricular systolic dysfunction (LVSD).Systematic review of the literature and meta-analysis of eligible studies providing data on end-diastolic and end-systolic volumes and left ventricular ejection fraction (LVEF) were performed.Data from 16 eligible studies were meta-analysed.Results of studies including patients with MI and preserved LVEF (>45%) showed no significant benefit of ACE inhibition.Of studies/subgroups with mean LVEF < or =45% demonstrated significant differences in diastolic and systolic volumes of 3.6.And 2.4) ml in short-term (4-14 weeks) follow-up in favour of ACE inhibitor, p=0.P=0.In the long-term (6-12 months) follow-up, the differences in diastolic and systolic volumes were 4.7.And 3.5.In favour of ACE inhibitor, p=0.P=0.LVEF improved in both short and long-term follow-up, p=0.P=0.Chronic use of ACE inhibition has a small but sustained and beneficial effect on remodelling in patients with myocardial infarction and patients with chronic left ventricular dysfunction.REFERENCES 1.MI – secondary prevention.2007.2.Post myocardial infarction.2007.3.Pedrazzini G, Santoro E, Latini R et al; GISSI-3 Investigators.Death in patients with acute myocardial infarction treated with angiotensin-converting enzyme inhibitors: findings from the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto (GISSI)-3 trial.Heart J.( 4.Abdulla J, Barlera S and Latini R et al.Review: effect of angiotensin converting enzyme inhibition on left ventricular volumes and ejection fraction in patients with a myocardial infarction and in patients with left ventricular dysfunction.J Heart Fail.() The NLH Question Answering Service aims to answer questions quickly, it is not a systematic review.You have any doubt as to the implications of this contact the Q&A Service Provider for further information.Read more Stimulation of fecal fat excretion and the disposal of protoporphyrin in a murine model for erythropoietic protoporphyria
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