Elsevier

The Lancet

Volume 354, Issue 9172, 3 July 1999, Pages 9-12
The Lancet

Articles
Effect of ACE inhibitor trandolapril on life expectancy of patients with reduced left-ventricular function after acute m yocardial infarction

https://doi.org/10.1016/S0140-6736(98)09374-XGet rights and content

Summary

Background

The survival benefit from the use of inhibitors of angiotensin-converting enzyme (ACE) in patients with acute myocardial infarction is usually presented in terms of risk ratios and lives saved per 1000 people treated. A more relevant way to present the extent of benefit would be in terms of an increase in life expectancy, but this approach has not previously been possible because of limited data on long-term outcome. We aimed to calculate the effect of trandolapril on life expectancy with follow-up data from the Trandolapril Cardiac Evaluation (TRACE) Study.

Methods

The TRACE study previously showed a significant survival benefit with trandolapril in patients with reduced left-ventricular function after an acute myocardial infarction who were treated for at least 2 years. We ascertained the survival status of all patients in the TRACE study in June, 1998, at which time they had been followed up for a minimum of 6 years. We estimated life expectancy as median lifetime, which was the time for 50% of the patients to have died. Change in life expectancy is expressed as change in median lifetime. Analysis was by intention to treat.

Findings

The life expectancy of patients was 4·6 years for those given placebo versus 6·2 years for those on trandolapril. Thus, for patients on trandolapril, median lifetime was increased by 15·3 months or 27% (95% Cl 7 to 51). Analysis of follow-up after the end of the study indicated no decrease of this benefit during the course of double-blind treatment; continued use of trandolapril was recommended at study closure.

Interpretation

In patients with severely reduced left-ventricular function, long-term treatment with an ACE inhibitor during the critical period after myocardial infarction is associated with a substantial increase in life expectancy.

Introduction

Three large studies1, 2, 3 showed a benefit of long-term use of inhibitors of angiotensin-converting enzyme (ACE) in patients who after an acute myocardial infarction have left-ventricular systolic dysfunction or clinical signs of congestive heart failure. This benefit is usually described in terms of hazard reduction, but many patients and physicians find this concept difficult to understand. Another commonly used way to describe benefit is in terms of lives saved per 1000 people treated. Although this approach is superficially simpler, it has the severe limitation of being restricted to a particular time point dictated by the length of the trial. An estimate of how much longer patients live when treated with an agent would be more useful, particularly to estimate the health gain and cost-effectiveness of a treatment. However, this approach requires long-term follow-up until a reliable estimate of life expectancy can be calculated. A useful estimate of increased life expectancy is the change in median lifetime until 50% mortality is reached in both treatment groups. The Trandolapril Cardiac Evaluation (TRACE) study has recorded outcome data for a minimum of 6 years in all patients who entered the original study. We aimed to calculate the life expectancy of these patients with the long-term follow-up data.

Section snippets

Patients

The details of the TRACE study have been described elsewhere.3, 4 6676 consecutive patients admitted with an enzyme-confirmed acute myocardial infarction to 27 Danish coronary care units were screened for entry to the study between May, 1990, and July, 1992. Left-ventricular function was determined by echocardiography. Eligible patients were those with a wall-motion index of 1·2 or less,5 which corresponds roughly to an ejection fraction of 35% or lower.6 Exclusion criteria were restricted to

Results

Of the 6676 patients with acute myocardial infarction screened for study entry, 2606 were eligible and 1749 were randomised to trandolapril or placebo. The study population thus represent a quarter of consecutive patients with acute myocardial infarction screened for entry and two-thirds of those with severe left-ventricular dysfunction. The mean age of these patients was 67 (SD 10) years, 1259 (72%) were men, and 1032 (59%) had symptoms of heart failure. Mortality curves to 7 years for both

Discussion

In patients with left-ventricular dysfunction after an acute myocardial infarction, long-term treatment with the ACE inhibitor trandolapril for at least 2 years increased their median lifetime by more than 1 year. Before the trial closed, nearly 40%3, 9 of patients had stopped the allocated treatment and at study closure most patients were advised to receive active therapy. Our analysis of subgroups of patients indicated the survival benefit was not distributed evenly. This finding was not

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