During the first few hours and days following an acute myocardial infarct, probably because of weakness of the ventricular muscle, there is stimulation of the renin-angiotensin system resulting in increased stretch of the ventricular muscle and mild-to-moderate cardiac enlarge¬ment occurs. This deleterious process is called ventricular remodeling. The remodeling process is decreased signifi¬cantly by ACE inhibitor therapy and morbidity and mortality is also decreased. Studies that show the efficacy of ACE inhibitors in patients with acute myocardial infarction are illustrated in the chapter Heart Attacks.
ACE inhibitors are recommended in most patients who have coronary heart disease, and particularly in diabetics.
This is based on the Heart Outcomes Prevention Evaluation (HOPE) study, which showed that in high-risk patients ramipril 10 mg, given for 4.5 years, caused a 22% reduction in the primary outcome of myocardial infarction, stroke, or death from cardiovascular causes.
The EUROPA study, which included 13655 patients with previous myocardial infarction (64%), angiographic evidence of coronary artery disease (61%), and coronary revascularization (55%) were randomized to perindopril 8 mg once daily or matching placebo. After a mean follow up of 4.2 years, perindopril administration caused improvement in outcome: about 50 patients needed to be treated for a period of 4 years to prevent one major cardiovascular event. Total mortality was 11% with perindopril, but this finding was not significant.

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