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CLINICAL STUDY

Beneficial effects of ramipril on left ventricular end-diastolic and end-systolic volume indexes after uncomplicated invasive revascularization are associated with a reduction in cardiac events in patients with moderately impaired left ventricular function and no clinical heart failure

^a Heart Center, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark

Manuscript received July 6, 2000; revised manuscript received November 12, 2000, accepted December 20, 2000.

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

OBJECTIVES

We sought to assess the effect of ramipril on left ventricular (LV) volumes, and the clinical significance thereof, in patients with moderate LV dysfunction and no clinical heart failure undergoing invasive revascularization for chronic stable angina.

BACKGROUND

It is unsettled whether treatment with an angiotensin-converting enzyme inhibitor has an impact on LV volumes in this patient group, and, if so, whether this is associated with the clinical outcome.

METHODS

A total of 133 patients with a left ventricular ejection fraction (LVEF) between 0.30 and 0.50 and no clinical heart failure undergoing invasive revascularization for chronic stable angina were randomized to receive ramipril 10 mg once daily or placebo and were followed for a median of 33 months with echocardiography at baseline and 3, 12 and 24 months postoperatively.

RESULTS

Repeated measures analysis of all time points showed that ramipril significantly reduced the end-diastolic volume index (EDVI) (p = 0.032) and end-systolic volume index (ESVI) (p = 0.006) as compared with placebo. Ramipril also reduced the incidence of the triple composite end point of cardiac death, acute myocardial infarction or development of heart failure (p = 0.046). Cox regression analysis, controlling for baseline LVEF and assignment to ramipril, revealed: 1) that increases in EDVI and ESVI up to three months predicted an increasing risk of a future adverse clinical outcome; and 2) that the benefit with ramipril on clinical outcome was partly dependent on a reduction in LV volumes.

CONCLUSIONS

Even in this patient group, LV dilation may supervene and lead to an adverse clinical outcome. Ramipril reduces the postoperative increase in LV volumes and may thereby improve clinical outcome.

Abbreviations and Acronyms   ACI = angiotensin-converting enzyme   AMI = acute myocardial infarction   APRES = Angiotensin-converting enzyme inhibition Post REvascularization Study   CABG = coronary artery bypass graft surgery   CI = confidence interval   EDVI = end-diastolic volume index   ESVI = end-systolic volume index   LV = left ventricular   LVEF = left ventricular ejection fraction   PTCA = percutaneous transluminal coronary angioplasty   RR = relative risk   SD = standard deviation   WMI = wall motion index   EDVI, ESVI, LVEF = increase from baseline in EDVI and ESVI and decrease from baseline in LVEF, respectively

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