Mortality Rates in Elderly Patients Who Take Different Angiotensin-Converting Enzyme Inhibitors after Acute Myocardial Infarction: A Class Effect?

20 July 2004 | Volume 141 Issue 2 | Pages 102-112

Background: Several randomized, controlled trials show that angiotensin-converting enzyme (ACE) inhibitors improve survival in patients who have had an acute myocardial infarction. However, existing data from trials do not address whether all ACE inhibitors benefit patients similarly.

Objective: To evaluate whether all ACE inhibitors are associated with similar mortality in patients 65 years of age or older who have had an acute myocardial infarction.

Design: Retrospective cohort study that used linked hospital discharge and prescription databases containing information on 18 453 patients 65 years of age or older who were admitted for an acute myocardial infarction between 1 April 1996 and 31 March 2000.

Setting: 109 hospitals in Quebec, Canada.

Patients: 7512 patients who filled a prescription for an ACE inhibitor within 30 days of discharge and who continued to receive the same drug for at least 1 year.

Measurements: The association between the specific drugs and clinical outcomes was measured by using Cox proportional hazards models, with adjustment for demographic, clinical, physician, and hospital variables and dosage categories, represented by time-dependent variables.

Results: Enalapril, fosinopril, captopril, quinapril, and lisinopril were associated with higher mortality than was ramipril; the adjusted hazard ratios and 95% CIs were 1.47 (95% CI, 1.14 to 1.89), 1.71 (CI, 1.29 to 2.25), 1.56 (CI, 1.13 to 2.15), 1.58 (CI, 1.10 to 2.82), and 1.28 (CI, 0.98 to 1.67), respectively. The adjusted hazard ratio associated with perindopril was 0.98 (CI, 0.60 to 1.60).

Limitations: The administrative databases did not contain detailed clinical information, and unmeasured factors associated with a patient's risk for death may have influenced physicians' prescription choices.

Conclusion: Survival benefits in the first year after acute myocardial infarction in patients 65 years of age or older seem to differ according to the specific ACE inhibitor prescribed. Ramipril was associated with lower mortality than most other ACE inhibitors.

Editors' Notes Context Do all angiotensin-converting enzyme (ACE) inhibitors similarly improve survival after myocardial infarction? Contribution This retrospective study linked hospital and prescription data from 18 453 patients 65 years of age and older who were admitted to 109 Canadian hospitals for myocardial infarction in the late 1990s. Patients who filled prescriptions for ramipril had lower mortality rates within the first year of hospital discharge than did those who filled prescriptions for several other ACE inhibitors, including captopril, enalapril, fosinopril, and quinapril. Cautions Although analyses controlled for multiple potential confounders, the authors could not adjust for unmeasured factors that might make the risk for death seem related to a particular ACE inhibitor. –The Editors

 

Author and Article Information

From The Montreal General Hospital, Jewish General Hospital, and McGill University, Montreal, Quebec, Canada.

Acknowledgments: The authors thank Hugues Richard and Roxane du Berger for statistical programming.

Grant Support: In part by The Canadian Institutes of Health Research (grant 93834). Dr. Pilote is funded by The Canadian Institutes of Health Research and holds a William Dawson Chair at McGill University. Dr. Abrahamowicz is a James McGill Professor at McGill University. Drs. Eisenberg and Rahme are funded by the Fonds de la Recherche en Santé du Québec (FRSQ).

Potential Financial Conflicts of Interest:Consultancies: E. Rahme (Pfizer, Merck & Co.); Grants received: E. Rahme (Pfizer, Merck & Co.).

Requests for Single Reprints: Louise Pilote, MD, MPH, PhD, Division of Clinical Epidemiology, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada; e-mail, louise.pilote{at}mcgill.ca.

Current Author Addresses: Drs. Pilote, Abrahamowicz, Rodrigues, and Rahme: Division of Clinical Epidemiology, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.

Dr. Eisenberg: Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, Suite A-118, 3755 Côte-Ste-Catherine Road, Montreal, Quebec H3T 1EZ, Canada.

Author Contributions: Conception and design: L. Pilote, M.J. Eisenberg, E. Rahme.

Analysis and interpretation of the data: L. Pilote, M. Abrahamowicz, E. Rodrigues, M.J. Eisenberg, E. Rahme.

Drafting of the article: L. Pilote, M. Abrahamowicz, E. Rodrigues, M.J. Eisenberg.

Critical revision of the article for important intellectual content: L. Pilote, M. Abrahamowicz, M.J. Eisenberg, E. Rahme.

Final approval of the article: L. Pilote, M. Abrahamowicz, E. Rodrigues, M.J. Eisenberg, E. Rahme.

Statistical expertise: L. Pilote, M. Abrahamowicz, M.J. Eisenberg, E. Rahme.

Obtaining of funding: L. Pilote.

Administrative, technical, or logistic support: L. Pilote.

Collection and assembly of data: L. Pilote, E. Rodrigues.

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