December 2006

A 55-year-old man with a history of hypercholesterolemia presented to the emergency department with severe crushing chest pain radiating to the left arm for a duration of 1 hour.

Using a retrospective observational study design, we assessed whether all angiotensin-converting enzyme (ACE) inhibitors had similar mortality rates after acute myocardial infarction in patients aged 65 years or older. Our results showed that mortality rates for enalapril, fosinopril, captopril, and quinapril were higher than that for ramipril. This suggests that there is no class effect for ACE inhibitors. Further research is needed to confirm the results of our study.

The problem of managing acute myocardial infarction (MI) in elderly patients, especially in those patients with left ventricular dysfunction, has multiple components, not the least of which is to decide which class of agents to use first (angiotensin-converting enzyme [ACE] inhibitors, diuretics, β blockers, etc) and whether to use these agents alone or in combination with 1 or more of the other classes of drugs.

We assessed whether there is a paradoxical increase in cardiovascular events with lower blood pressure values among patients with hypertension and coronary artery disease (CAD) who were enrolled in the International Verapamil-Trandolapril Study (INVEST). The relationship between systolic and diastolic pressure and the risk of primary outcome followed a J-curve pattern, with the relationship being relatively weak for systolic pressure but more significant for diastolic pressure. Our data indicate that excessive lowering of diastolic pressure in hypertensive patients with CAD should be avoided.

The manuscript by Messerli and colleagues, entitled "Dangers of aggressively lowering blood pressure in coronary artery disease," raises a controversial issue with important clinical implications—the J-shaped curve.

We performed a systematic literature review and meta-analysis to evaluate the efficacy of angiotensin-converting enzyme inhibitors in patients with coronary artery disease and normal systolic left ventricular function. Angiotensin- converting enzyme inhibitor use was associated with modest benefits, which included a reduction in cardiovascular mortality, nonfatal myocardial infarction, and revascularization rates.

Angiotensin-converting enzyme (ACE) inhibitors have been shown to be beneficial in the management of multiple cardiovascular disease states.