A Cochrane review [Abstract] 1 on effect of early treatment with ACE inhibitors (12 studies, n=84 456), beta-blockers (20), calcium channel blockers (CCBs) (18) and nitrates (18) on short and long-term mortality in patients with an acute cardiovascular event included 65 studies with a total of 166 206 subjects. Immediate ACE inhibitor treatment (started within 24 hours of the onset and lasting for maximum 2 days) was associated with a statistically non-significant reduction in all-cause mortality at 2 days (RR 0.91, 95% CI 0.82 to 1.00; 3 studies, n=77 414) and at 10 days (RR 0.68, 95% CI 0.12 to 3.98; 2 studies, n=145) in acute myocardial infarction. Short-term treatment (started within 24 hours of the onset and lasting for a maximum of 10 days) with ACE inhibitor was associated with a statistically significant reduction in all cause mortality at 10 days as compared to placebo (RR 0.93, 95% CI 0.87 to 0.98; 10 studies, n=84 311). No trial reported mortality at ≥ 30 days.
The 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 2 states that ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease unless contraindicated (e.g. severe renal impairment, hyperkalaemia etc.) in order to reduce all-cause and cardiovascular mortality and cardiovascular morbidity.
The 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 3 states that ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are recommended, starting within the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or an anterior infarct, and ACE inhibitors should be considered in all STEMI patients in the absence of contraindications.
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