A report in the 25 September issue of the Archives of Internal Medicine says that angiotensin-converting enzyme (ACE) inhibitors safely reduce mortality after myocardial infarction in patients with moderate renal insufficiency.
To determine whether ACE inhibitor therapy should be contraindicated in renal insufficiency, Dr. Craig
Frances, of the Veterans Affairs Medical Center, in San Francisco, California, and colleagues evaluated
the survival of 20,902 patients aged 65 years and older who had depressed left ventricular function after a
confirmed MI. Patients with renal insufficiency are often excluded from ACE inhibitor therapy, the authors explain.
ACE inhibitor treatment improved survival by 37% in
patients with elevated serum creatinine levels and by 16% in patients with lower serum creatinine levels,
the report indicates. Patients with serum creatinine levels above 265 micromoles/L had 20% lower 1-year survival than patients
with lower creatinine levels, the authors report.
Adding aspirin to ACE inhibitor therapy significantly attenuated its benefits, the investigators note. In
patients with normal renal function, the combination slightly (but not significantly) increased 1-year
mortality, while the survival benefits of ACE inhibitor therapy for patients with renal insufficiency
disappeared with the addition of aspirin to the regimen.
"We believe that moderate renal insufficiency should not be considered a contraindication to the use of
ACE inhibitor therapy for patients who have poor left ventricular ejection fraction following MI," the authors
Rather, they advise, "patients with renal insufficiency should receive a lower initial dose of an ACE
inhibitor, undergo careful monitoring of their serum potassium and creatinine levels, and perhaps avoid
using inhibitors of prostaglandin synthesis (eg, especially potent nonsteroidal anti-inflammatory drugs)."