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CLINICAL STUDIES

The Angiotensin-converting Enzyme Inhibition Post Revascularization Study (APRES)

^a The Heart Center, Rigshospitalet, Copenhagen, Denmark

Manuscript received March 17, 1999; revised manuscript received October 15, 1999, accepted November 19, 1999.

Reprint requests and correspondence: Dr. Lars Kjøller-Hansen, Heart Center 2142, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
kjol-h{at}dadlnet.dk

OBJECTIVE

This study was performed to assess the effect of treatment with ramipril on the incidence of cardiac events after invasive revascularization in patients with asymptomatic moderate left ventricular dysfunction.

BACKGROUND

In patients with angina pectoris and left ventricular dysfunction, both invasive revascularization and treatment with angiotensin-converting enzyme inhibitors reduce cardiac mortality and morbidity. Whether there is a benefit from combining the two treatment strategies has never been evaluated prospectively.

METHODS

After invasive revascularization, 159 patients with preoperative chronic stable angina pectoris, left ventricular ejection fraction between 0.30 and 0.50 and no clinical heart failure were randomly assigned to receive double-blind treatment with either ramipril or placebo and subsequently followed for a median of 33 months.

RESULTS

Ramipril reduced the incidence of the triple-composite end point of cardiac death, acute myocardial infarction or clinical heart failure (risk reduction 58%; 95% confidence interval 7% to 80%, p = 0.031). The incidence of the quadruple-composite end point of cardiac death, acute myocardial infarction, clinical heart failure or recurrent angina pectoris was not altered with ramipril. These findings were consistent across subgroups with respect to left ventricular ejection fraction below or above 0.40, and whether coronary artery bypass grafting or percutaneous transluminal coronary angioplasty was performed.

CONCLUSIONS

In patients with angina pectoris and asymptomatic moderate left ventricular dysfunction, long-term treatment with ramipril after invasive revascularization significantly reduced the incidence of the composite end point of cardiac death, acute myocardial infarction or clinical heart failure, indicating that the beneficial effects of angiotensin-converting enzyme inhibitor treatment may be extended to include treatment of this patient group.

Abbreviations and Acronyms   4S = Scandinavian Simvastatin Survival Study   ACE-I = angiotensin-converting enzyme inhibitor   AMI = acute myocardial infarction   APRES = Angiotensin-converting Enzyme Inhibition Postrevascularization Study   CABG = coronary artery bypass grafting   CASS = coronary artery surgery study   LVEF = left ventricular ejection fraction   NNT = numbers needed to treat   PTCA = percutaneous transluminal coronary angioplasty

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