ACE inhibitors and sudden cardiac death in patients following acute myocardial infarction
A topic in Clinical Evidence 2 summarizes the evidence on ACE inhibitors within 36 hours of the onset of symptoms of AMI, irrespective of clinical heart failure or left ventricular dysfunction. An overview of 4 RCTs (98,496 subjects) found that ACER inhibitors significantly reduced mortality at 30 days (7.1% with ACE inhibitors v 7.6% with placebo, RR 0.93, 95% CI 0.89 to 0.98, NNT = 200). The absolute benefit was larger in some high risk groups (people with clinically moderate to severe heart failure RR 0.91, NNT = 71; people with heart rates greater than 100 bpm RR 0.86, NNT = 44; people with anterior AMI RR 0.87, NNT = 94). Three RCTs (n=6,000) found consistently that long term treatment with ACE inhibitors reduced mortality and reinfarction (RRRs from 1 trial for cardiovascular death 21%, 95% CI 5 to 35%, for development of severe heart failure 37%, 95% CI 20 to 50%, congestive heart failure requiring admission to hospital 22%, 95% CI 4 to 37%, recurrent AMI 25%, 95% CI 5 to 40%). Clinical evidence category: Beneficial.
A systematic review 1 including 15 RCTs with a total of 15,104 subjects with an acute myocardial infarction in the previous 14 days was abstracted in DARE. Total mortality was lower in patients treated with ACE inhibitors (OR 0.83, 95% CI 0.71 to 0.97), and there were fewer cardiovascular deaths (OR 0.82, 95% CI 0.69 to 0.97). The OR for non-cardiovascular deaths was 0.87 (95% CI 0.69 to 1.09). The OR for sudden cardiovascular deaths was 0.80 (95% CI 0.70 to 0.92).
The following decision support rules contain links to this evidence summary:
- ACE inhibitors after acute myocardial infarction http://www.ebmeds.org/ebmeds/ebmeds_home.asp...
1. Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol 1999 Mar;33(3):598-604. [PMID:10080457]
2. Danchin N, Urban P, De Benedetti E. Acute myocardial infarction. Clin Evid 2002 Jun;(7):11-35. [PMID:12230636]
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