Circulation, Vol 89, 68-75, Copyright © 1994 by American Heart Association
M St. John Sutton, MA Pfeffer, T Plappert, JL Rouleau, LA Moye, GR Dagenais, GA Lamas, M Klein, B Sussex and S Goldman
BACKGROUND: Left ventricular enlargement after myocardial infarction
increases the likelihood of an adverse outcome. In an echocardiographic
substudy of the Survival and Ventricular Enlargement (SAVE) Trial, we
assessed whether captopril would attenuate progressive left ventricular
enlargement in patients with left ventricular dysfunction after acute
myocardial infarction and, if so, whether this would be associated with
improved clinical outcome. METHODS AND RESULTS: Two-dimensional
transthoracic echocardiograms were obtained in 512 patients at a mean of
11.1 +/- 3.2 days after infarction and were repeated at 1 year in 420
survivors. Left ventricular size was assessed as left ventricular cavity
areas at end diastole and end systole and left ventricular function as
percent change in cavity area from end diastole to end systole. Patients
were randomly assigned to placebo or captopril, and the incidence of
adverse cardiovascular events consisting of cardiovascular death, heart
failure requiring either hospitalization or open-label
angiotensin-converting enzyme inhibitor therapy, and recurrent infarction
were determined over a follow-up period averaging 3.0 +/- 0.6 years.
Irrespective of treatment assignment, baseline left ventricular systolic
area and percent change in area were strong predictors of cardiovascular
mortality and adverse cardiovascular events. At 1 year, left ventricular
end-diastolic and end-systolic areas were larger in the placebo than in the
captopril group (P = .038, P = .015, respectively), and percent change in
cavity area was greater in the captopril group (P = .005). One hundred
eleven of the 420 1-year survivors with 1-year echo measurements (26.4%)
experienced a major adverse cardiovascular event, and these patients had
more than a threefold greater increase in left ventricular cavity areas
than those with an uncomplicated course. Sixty-nine patients with adverse
cardiovascular events were in the placebo group compared with 42 patients
in the captopril-treated group (a risk reduction of 35%, P = .010).
CONCLUSIONS: Two-dimensional echocardiography provides important and
independent prognostic information in patients after infarction. Left
ventricular enlargement and function after infarction are associated with
the development of adverse cardiac events. Attenuation of ventricular
enlargement with captopril in these patients was associated with a
reduction in adverse events. This study demonstrates the linkage between
attenuation of left ventricular enlargement by captopril after infarction
and improved clinical outcome.
ARTICLES
Quantitative two-dimensional echocardiographic measurements are major predictors of adverse cardiovascular events after acute myocardial infarction. The protective effects of captopril
Brompton Hospital, London, England.
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