Oral captopril versus placebo among 13 634 patients with suspected acute myocardial infarction: interim report from the Chinese Cardiac Study (CCS-1)

doi:10.1016/S0140-6736(95)90866-8

The Lancet

Volume 345, Issue 8951, 18 March 1995, Pages 686-687

https://doi.org/10.1016/S0140-6736(95)90866-8 Get rights and content

Abstract

13 634 patients entering 650 Chinese hospitals up to 36 h after the onset of suspected acute myocardial infarction (Ml) were randomised between one month of oral captopril (6·25 mg initial dose, 12·5 mg 2 h later, and then 12·5 mg three times daily) or matching placebo. Captopril was associated with a non-significant reduction in 4-week mortality (617 [9·05%] captopril-allocated vs 654 [9·59%] placebo-allocated deaths; 2p=0·3). There was a significant excess of hypotension, mostly early after the start of treatment, but no evidence of any adverse effect on early mortality (even among patients who were hypotensive at entry). Taken together with the other trials of converting enzyme inhibitors started early in acute Ml, these results indicate that such therapy is generally safe and typically prevents about 5 deaths per 1000 patients treated for the first month.

References (4)

ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58 050 patients with suspected acute myocardial infarction
Lancet
(1995)

There are more references available in the full text version of this article.

Cited by (281)

Modern Management of ST-Segment Elevation Myocardial Infarction
2020, Current Problems in Cardiology
Citation Excerpt :
At 15 months, ramipril was associated with lower mortality than placebo (17% vs 23%, P = 0.002). These and the other major trials203-205 of ACE inhibitors after AMI are summarized in Table 4. ARBs were tested head-to-head with ACE inhibitors after AMI in the Optimal Trial in Myocardial Infarction with the Angiotensin II Antagonist Losartan (OPTIMAAL)206 and Valsartan in Acute Myocardial Infarction Trial (VALIANT)207 trials, and neither found ARBs to be superior.
Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for ST-segment elevation myocardial infarction (STEMI). Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies. The purpose of this review is to discuss the epidemiology, pathophysiology, and diagnosis of STEMI. In addition, the review will focus on guideline-directed therapy for these patients and review potential associated complications.
Impact of renin-angiotensin system blockade on the prognosis of acute coronary syndrome based on left ventricular ejection fraction
2020, Revista Espanola de Cardiologia
No está clara la asociación entre los inhibidores de la enzima de conversión de la angiotensina (IECA) o los antagonistas del receptor de la angiotensina II (ARA-II) y la mortalidad de los pacientes con síndrome coronario agudo (SCA) sometidos a intervención coronaria percutánea (ICP) con fracción de eyección del ventrículo izquierdo (FEVI) conservada. Nuestro objetivo es determinar dicha asociación en pacientes con FEVI conservada o reducida.
Se analizaron datos procedentes del registro BleeMACS. El objetivo principal fue la mortalidad a 1 año. Se aplicaron ponderación por la probabilidad inversa del tiempo de supervivencia y ajustes por regresión de Cox, puntuación de propensión y variables instrumentales.
De los 15.401 pacientes con SCA sometidos a ICP, se prescribieron IECA/ARA-II al 75,2%. Se produjeron 569 muertes (3,7%) durante el primer año tras el alta hospitalaria. Después del ajuste multivariado, los IECA/ARA-II se asociaron con menor mortalidad, pero solo en los pacientes con FEVI ≤ 40% (HR = 0,62; IC95%, 0,43-0,90; p = 0,012). Con los IECA/ARA-II, la reducción del riesgo relativo de la mortalidad estimada fue del 46,1% en los pacientes con FEVI ≤ 40% y del 15,7% en aquellos con FEVI > 40% (p_interacción = 0,008). En los pacientes con FEVI > 40%, los IECA/ARA-II se asociaron con menor mortalidad solo por infarto agudo de miocardio con elevación del segmento ST (HR = 0,44; IC95%, 0,21-0.93; p = 0,031).
El beneficio de los IECA/ARA-II en mortalidad tras ICP por SCA se concentra en pacientes con FEVI ≤ 40% y aquellos con FEVI > 40% e infarto agudo de miocardio con elevación del segmento ST. Se precisan estudios contemporáneos que analicen el impacto de los IECA/ARA-II en pacientes con SCA sin elevación del segmento ST y FEVI > 40%.
For patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.
Data from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.
Among 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P = .012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF > 40% (P value for treatment-by-LVEF interaction = .008). For patients with LVEF > 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P = .031).
The benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF > 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF > 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.
From ACE Inhibitors/ARBs to ARNIs in Coronary Artery Disease and Heart Failure (Part 2/5)
2019, Journal of the American College of Cardiology
The pharmacological inhibition of the renin-angiotensin-aldosterone system as a therapeutic strategy is one of the most significant advances in the treatment and prevention of cardiovascular disease in heart failure with reduced ejection fraction and in coronary artery disease. Recently, the addition of neprilysin inhibition to angiotensin receptor blockade has been shown to be even more effective than angiotensin-converting enzyme inhibition alone in heart failure with reduced ejection fraction, marking an important new milestone in heart failure treatment. This review summarizes the major trials that have informed the clinical role of inhibition of the renin-angiotensin-aldosterone and neprilysin pathways, as well as the limitations of these strategies.
Adjunctive pharmacologic therapies in acute myocardial infarction
2018, Cardiac Intensive Care
Heart Failure Complicating Acute Mtyocardial Infarction
2017, Heart Failure Clinics
Mortality benefit of long-term angiotensin-converting enzyme inhibitors or angiotensin receptor blockers after successful percutaneous coronary intervention in non-ST elevation acute myocardial infarction
2016, Revista Portuguesa de Cardiologia
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have been shown to reduce mortality after myocardial infarction (MI). Current guidelines recommend their prescription in all patients after MI. Limited data are available on whether ACEIs/ARBs still improve prognosis in the contemporary era of non-ST elevation MI (NSTEMI) management. We aimed to evaluate the mortality benefit of ACEIs/ARBs in NSTEMI patients treated successfully with percutaneous coronary intervention (PCI).
We analyzed 2784 patients with NSTEMI treated successfully with in-hospital PCI. Two groups were formed based on ACEI/ARB prescription at discharge. Two propensity score (PS) analyses were performed to control for differences in covariates: one with adjustment among the entire cohort, and the other with PS matching (n=1626). The outcome variable was all-cause mortality at four-year follow-up.
There were 1902 (68.3%) patients prescribed ACEIs/ARBs at discharge. When adjusted by PS, ACEI/ARB use was associated with a hazard ratio (HR) for mortality of 0.75 (0.60-0.94; absolute risk reduction [ARR] 4.0%) in the whole cohort (p=0.01).
After one-to-one PS matching (n=813 in each group), the mortality rate was significantly lower in patients prescribed ACEIs/ARBs, with HR of 0.77 (0.63-0.94; ARR 3.8%) (p=0.03).
In this observational study of patients with NSTEMI, all of them treated successfully by PCI, the use of ACEIs/ARBs was significantly associated with a lower risk of four-year all-cause mortality.
Os inibidores da enzima de conversão da angiotensina (IECA) ou os antagonistas do recetor da angiotensina (ARA) mostraram reduzir a mortalidade após enfarte do miocárdio (EM). As guias internacionais atuais recomendam a sua prescrição a todos os doentes após EM. Existem poucos dados disponíveis relativamente a se os IECA/ARA continuam a melhorar o prognóstico na abordagem atual do EM sem elevação do segmento ST (EMSEST). O nosso objetivo foi avaliar o benefício em termos de mortalidade dos IECA ou ARA em doentes com EMSEST, tratados com intervenção coronária percutânea (ICP) com sucesso.
Analisámos 2784 doentes com EMSEST tratados, de forma bem-sucedida, com ICP durante o internamento hospitalar. Foram constituídos dois grupos com base na prescrição de IECA/ARA aquando da alta. Foram efetuadas duas análises de propensity score para controlar diferenças nas co variáveis: uma com ajuste entre toda a coorte e outra com propensity score matching (n=1,626). A variável resultado foi a mortalidade por qualquer causa, após quatro anos de seguimento.
Houve 1902 (68,3%) de doentes com IECA/ARA prescritos aquando da alta. Quando ajustado para o propensity score, o uso de IECA/ARA associou-se a um hazard ratio de 0,75 para mortalidade (0,60-0,94; redução do risco absoluto [RRA] 4,0%) em toda a coorte (p=0,01).
Após o one-to-one propensity score matching (n=813 em cada grupo), a taxa de mortalidade foi significativamente menor em doentes sob tratamento com IECA/ARA, com um hazard ratio de 0,77 (0,63-0,94; RRA 3,8%) (p=0,03).
Neste estudo observacional de doentes com EAMSEST, todos tratados com ICP com sucesso, o uso de IECA/ARA esteve associado a um risco significativamente menor de mortalidade por todas as causas aos quatro anos.

View all citing articles on Scopus

¹: Collaborators are listed at the end of the report Correspondence to: Dr Liu Lisheng, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China

View full text

Oral captopril versus placebo among 13 634 patients with suspected acute myocardial infarction: interim report from the Chinese Cardiac Study (CCS-1)

Abstract

ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58 050 patients with suspected acute myocardial infarction

Lancet