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PubMed1994

Primary isolated coronary artery bypass in left ventricular dysfunction: survival and predictors of survival.

Coronary angiograms of 462 patients with ejection fractions below 51% who underwent primary isolated coronary artery bypass at the Cleveland Clinic from 1981 to 1985 were available for review. They were divided into two groups: group 1 (n = 166) with severe ventricular dysfunction (ejection fraction less than 30%) and group 2 (n = 296) with moderate ventricular dysfunction (ejection fraction 31 to 50%) at a median follow-up of 5.8 years/patient. The actuarial survival was 64.3% in group 1 and 80.6% in group 2 (P = 0.0001). By multivariate analysis, congestive heart failure (P = 0.0001) was the single most important factor affecting survival for both groups. In addition, in group 1 the preoperative use of inotropes (P = 0.03) and in group 2 the presence of peripheral vascular disease (P = 0.001) affected long term survival.

Actuarial Analysis↗
PubMedDate not supplied

Angiotensin-converting enzyme inhibitors in left ventricular dysfunction.

Angiotensin-converting enzyme (ACE) inhibitors have been used for more than a decade in the treatment of chronic congestive heart failure. In recent years these agents have been used in patients who survived a myocardial infarction. However, primary care providers are often confused as to which patients would benefit the most, and as a result, these life-prolonging drugs are underutilized. The results of randomized controlled trials evaluating ACE inhibitors' effect on morbidity and mortality in patients with chronic congestive heart failure or acute myocardial infarction were evaluated. Angiotensin-converting enzyme inhibitors clearly improve survival in patients with symptomatic congestive heart failure. This survival benefit is approximately 6 months. In patients with asymptomatic systolic dysfunction, these agents also decrease the number of hospital admissions due to heart failure. Angiotensin-converting enzyme inhibitors also improve survival in all patients who experienced an acute myocardial infarction. With the plethora of evidence regarding the positive effects that this class of drugs has on the quality of life and survival of patients with systolic dysfunction, it is still unclear why clinicians are reluctant to use them more often. Primary care providers need to be educated on how to risk stratify patients to make this therapy more cost effective, and when these agents should be started.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1996

What have the ACE-inhibitor trials in postmyocardial patients with left ventricular dysfunction taught us?

A series of elegant experimental studies and careful clinical observation over a decade or more have led to the concept of 'infarct expansion' and 'remodelling' of the heart, culminating in a number of major mortality studies indicating the effectiveness of angiotensin-converting enzyme (ACE) inhibitors in patients after myocardial infarction (MI). But has this concept been too narrow in predicting which patients might benefit from treatment with ACE inhibitors? Measurable infarct-expansion with progressive dilatation probably occurs in less than 20% of patients, whereas increase in volume and hypertrophy of the heart as responses to compromised function are likely wherever significant myocardial damage has occurred. Irrespective of infarct expansion, cumulative extensive damage can lead to an inevitable downward spiral with gross ventricular dilatation and death in heart failure. But in the majority of patients after MI a 'new equilibrium' is established in which initial dilatation and subsequently hypertrophy restore adequate function. Is it possible to distinguish patients in whom the cost and inconvenience of long-term therapy with an ACE inhibitor justify the likely benefit from treatment after an MI? The SAVE, AIRE and recent TRACE studies allow a rational approach for the clinician, indicating the effectiveness of these drugs in patients with evidence of impaired ventricular function. However, the prospect that ACE inhibitors prescribed long term might also prevent myocardial reinfarction could justify wider use. Post-MI patients are an easily identifiable high-risk group for a cost-effective programme of secondary prevention. Reinfarction in an already damaged ventricle carries a particularly poor prognosis and its prevention by ACE inhibitors could make a major contribution to the undoubted benefit from these agents. The recently completed TRACE study with its long-term follow-up may help resolve this issue, which is also being investigated in a number of long-term prospective studies in populations at high risk of cardiovascular disease.

Angiotensin-Converting Enzyme Inhibitors↗