Fig. 2. Life table of cumulative need for revascularization (by either percutaneous coronary angioplasty or coronary artery bypass surgery) after randomization. For this combined analysis, the time to first event was used. Data from ref. 35.
cular mortality, 37% for development of severe congestive heart failure, and 22% for heart failure requiring hospitalization. Thus, SAVE established the role of ACE inhibition in the treatment of patients after MI with low EFs.
Although the primary end point of SAVE focused on the assessment of survival and prevention of deterioration of LV function, recurrent MI was a prospectively defined and carefully sought end point. The captopril-treated group demonstrated a 25% relative reduction in the risk of recurrent MI. A more detailed analysis for predictors of MI by Rutherford et al. (35) demonstrated that LV EF was not a predictor of recurrent MI. Cap-topril therapy was associated with similarly decreased risk of reinfarction for SAVE patients with EFs above and below the median. Furthermore, captopril therapy also decreased the incidence of angioplasty or bypass surgery (relative reduction in risk 24%, p = 0.014) when compared to placebo (Fig. 2). Lamas et al. (36) demonstrated that the principal predictor of recurrent infarction was the number of vessels diseased and not revascularized. Captopril therapy reduced the incidence of recurrent infarction in patients with single, as well as multivessel, disease.
Studies of Left Ventricular Dysfunction (SOLVD) randomized 6797 patients in two separate placebo-controlled trials of enalapril in LV dysfunction—a treatment arm (37) and a prevention arm (38). All patients had an EF of <35%. Patients in the prevention arm had asymptomatic LV dysfunction, and patients in the treatment arm had clinically established heart failure. Although SOLVD was a trial of patients with chronic LV dysfunction of any etiology, 79% were thought to have an ischemic cardiomyopathy. However, no patient in either trial had unstable angina at the time of enrollment nor had suffered an AMI in the month before enrollment. There was a reduction in risk of MI of 23% and unstable angina of 20% in the enalapril-treated group.
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