ACE Inhibitors in Acute Myocardial Infarction

Angiotensin-converting enzyme inhibitors have earned their place along with aspirin, β-blockers, and thrombolytic agents as medical therapies proven to reduce mortality rates in acute myocardial infarction.1 The results of well-conducted, randomized, controlled clinical trials have been so consistent and so conclusive that the emphasis now shifts from research to implementation. Because the trials demonstrated that the oral use of an ACE inhibitor can save lives, the pragmatic questions of who and when to treat are left to the frontline physicians. Unlike the clinical trial experience with its protocol-directed inclusion and exclusion criteria, time window for initiation, and the informed consent process, the practicing physician must make decisions on the basis of his or her current assessment of the relative merits as well as the potential for harm by an ACE inhibitor for individual patients. Because any further major placebo-controlled trials of ACE inhibitors in acute myocardial infarction are not likely, physicians must use the sum of the currently available information to make the best choices for their patients.2 The leaders of major trials of antiplatelet3 and thrombolytic4 therapies in acute myocardial infarction have formed collaborative groups that pool their collective data in an attempt to better understand the safety and efficacy information of their combined experience. This collaborative approach goes a step beyond routine meta-analysis because the group not only attempts to develop more uniform definitions but, importantly, pools their individual data to derive more reliable life-table experiences and projections. An ACE Inhibitor Collaborative Group was convened with these same objectives in the hope of developing a consensus for recommending ACE inhibitors in patients with acute myocardial infarction. One of the group’s initial decisions was to categorize the ACE inhibitor trials of myocardial infarction into those that were early-onset, broad-inclusion and short-term trials or selective-inclusion, long-term …