ArticlesEffect of ACE inhibitor trandolapril on life expectancy of patients with reduced left-ventricular function after acute m yocardial infarction
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
References (14)
- et al.
Clincal characteristics and mortality of patients screened for entry into the Trandolapril Cardiac Evaluation (TRACE) Study
Am J Cardiol
(1995) - et al.
Angiotensin-converting enzyme inhibition after myocardial infarction: the Trandolapril Cardiac Evaluation Study
Am Heart J
(1996) - et al.
Follow-up study of patients randomly allocated ramipril or placebo for heart failure after acute myocardial infarction: AIRE Extension (AIREX) Study
Lancet
(1997) Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure
Lancet
(1993)- et al.
Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the Survival and Ventricular Englargement Trial
N Engl J Med
(1992) - et al.
A clinical trial of the angiotensin converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction
N Engl J Med
(1995) - et al.
An echocardiographic method for selecting high risk pateints shortly after acute myocardial infarction, for inclusion in multicentre studies as used in the TRACE study
Eur Heart J
(1994)