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Four large multicentre studies (SAVE, AIRE, GISSI-3, ISIS-4)'-, have now reported beneficial effects of angiotensin converting enzyme (ACE) inhibitors after acute myocardial infarction. However, their relevance to current clinical practice remains unclear, largely because the populations randomized in these trials were very different due to variations in inclusion and exclusion criteria. Although the data may be interpreted as supporting the universal use of ACE inhibitors in patients following acute myocardial infarction, this 'one size fits all' approach dilutes the benefits, which are concentrated in higher risk subgroups such as those with anterior wall infarction, heart failure and prior infarction'. To use a more selective approach will require well defined and readily available criteria for identifying patients likely to benefit from ACE inhibitor therapy. The AIRE study provides simple clinical guidelines for the treatment of a high risk group with clinical evidence of heart failure''. However, as shown in the SAVE study, if clinical signs alone are used to select patients for ACE inhibitor therapy, then many patients likely to benefit will be excluded. The SAVE study selected patients with left ventricular ejection fractions <40% and found that the mortality benefit with ACE inhibitors was seen equally in those without clinically overt heart failure (Killip Class I) as in those with overt heart failure''. This means that as well as the 20-30% of post-acute myocardial infarction patients who show clinical evidence of heart failure, an additional 26% of patients with asymptomatic left ventricular dysfunction will also benefit from ACE inhibitor therapy''. The method most commonly used to identify this latter group is estimation of the left ventricular ejection fraction by any of several cardiac imaging techniques. Radionuclide ventriculography is an accurate way of measuring left ventricular ejection fraction,

Can qualitative echocardiography be used to select patients for angiotensin-converting enzyme inhibitors following acute myocardial infarction?