CardioMan - Case 1

Case 1:

JF is a 42-year old previously healthy farmer who presented with sudden onset central chest pain of one hour duration to the ED. The pain is associated with sweating and radiates to the left arm and jaw. The area of discomfort is about the size of the fist.

Ragavendra R. Baliga, M.D
Assistant Professor
Division of Cardiology
University Of Michigan

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Question 29 of 39:

This patient should be administered an ACE inhibitor within the first 24 hours of symptoms even if he has a normal ejection fraction.

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Patients within the first 24 hours of a suspected MI with ST-segment elevation in 2 or more anterior precordial leads or with clinical heart failure in the absence of hypotension (SBP<100 mm Hg) or known contra-indication to the use of ACE inhibitors.

A number of large randomized clinical trials have assessed the role of ACE inhibitors early in the course of MI. All trials in which the only oral ACE inhibitors were used demonstrated a benefit in mortality. It appears that the benefits of ACE inhibitors are greater among those with an anterior infarct or who have evidence of previous infarction, heart failure, and tachycardia, i.e., those at highest risk. Data from these trials indicate that ACE inhibitors should generally be started within the first 24 hours, ideally, after thrombolytic therapy has been completed and the blood pressure has been stablilized.

Graded dose schedules should be used with ACE inhibitors. For example in the ISIS-4 trial an initial dose of 6.25 mg dose of captopril was give, followed by 12.5 mg 2 hours later, 25 mg 10 to 12 hours later and then 50 mg twice a day. GISSI trial patients received 5 mg oral lisinopril at the time of randomization, 5 mg after 24 hours, 10 mg after 48 hours and then 10 mg daily for 6 weeks.

Intravenous enalaprilat should be avoided. The CONSENSUS-2 trial used intravenous enalaprilat and was terminated early because of the high probability that a significant beneficial effect of enalapril over placebo was unlikely to be demonstrated, as well as a concern over an adverse effect among elderly patients experiencing an early hypotensive reaction. The 95% confidence limits ranged from showing 7% benefit to 29% harm.

In those patients with low ejection fraction ACE inhibitors should be continued life-long (SOLVD trial) whereas those with normal ejection fraction low dose ramipril should be continued life long (HOPE trial).