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Wu J, Hall AS, Gale CP Long-term survival benefit of ramipril in patients with acute myocardial infarction complicated by heart failure. Heart. 2021 Mar;107(5):389-395. doi: 10.1136/heartjnl-2020-316823. Epub 2021 Jan 15. (Original study)

AIMS: ACE inhibition reduces mortality and morbidity in patients with heart failure after acute myocardial infarction (AMI). However, there are limited randomised data about the long-term survival benefits of ACE inhibition in this population.

METHODS: In 1993, the Acute Infarction Ramipril Efficacy (AIRE) study randomly allocated patients with AMI and clinical heart failure to ramipril or placebo. The duration of masked trial therapy in the UK cohort (603 patients, mean age=64.7 years, 455 male patients) was 12.4 and 13.4 months for ramipril (n=302) and placebo (n=301), respectively. We estimated life expectancy and extensions of life (difference in median survival times) according to duration of follow-up (range 0-29.6 years).

RESULTS: By 9 April 2019, death from all causes occurred in 266 (88.4%) patients in placebo arm and 275 (91.1%) patients in ramipril arm. The extension of life between ramipril and placebo groups was 14.5 months (95% CI 13.2 to 15.8). Ramipril increased life expectancy more for patients with than without diabetes (life expectancy difference 32.1 vs 5.0 months), previous AMI (20.1 vs 4.9 months), previous heart failure (19.5 vs 4.9 months), hypertension (16.6 vs 8.3 months), angina (16.2 vs 5.0 months) and age >65 years (11.3 vs 5.7 months). Given potential treatment switching, the true absolute treatment effect could be underestimated by 28%.

CONCLUSION: For patients with clinically defined heart failure following AMI, ramipril results in a sustained survival benefit, and is associated with an extension of life of up to 14.5 months for, on average, 13 months treatment duration.

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 7 / 7
General Internal Medicine-Primary Care(US) 7 / 7
Internal Medicine 6 / 7
Cardiology 6 / 7
Comments from MORE raters

Cardiology rater

Long term data are important, especially in this population.

General Internal Medicine-Primary Care(US) rater

The large and long-term effect is surprising. That the effect size is greater in older adults is also remarkable.

Internal Medicine rater

As an Internist, I found this information very useful for treatment of heart failure patients after myocardial infarction.

Internal Medicine rater

As the authors indicated, they were not able to establish which medications patients may have received or had taken after the end of the trial, which could have biased the results in those in the ramipril arm had they received ACE inhibition and/or contemporary secondary prevention therapies compared with patients in the placebo arm during the additional follow-up term. Thus, this study is a retrospective one. Caution would be necessary to evaluate the results.
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