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 - Beneficial Effects of Ramipril on Left Ventricular End-Diastolic and End-Systolic Volume Indexes

Description:

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.

Hypothesis:

Does treatment of patients with moderate left ventricular (LV) dysfunction and no clinical heart failure undergoing invasive revascularization for chronic stable angina impact LV volumes and function? If so, is this effect on LV size and function associated with clinical benefit?

Study Design

Study Design:

Patients Enrolled: 133

Drug/Procedures Used:

Patients with impaired left ventricular ejection fraction (LVEF 0.30-0.50) and no clinical heart failure undergoing revascularization (n=133) were randomized to receive ramipril 10mg once daily or placebo for a median of 33 months with serial echocardiography (at baseline preprocedure, and 3, 12 and 24 months postoperatively).

Principal Findings:

Ramipril significantly reduced the LV end-diastolic volume index (EDVI) (p = 0.032) and LV end-systolic volume index (ESVI) (p = 0.006) at all time points as compared with placebo. The LVEF remained similar to baseline in ramipril group with a trend toward a fall in LVEF in the placebo group (p=0.15 for ramipril vs. placebo). Ramipril treatment was associated with reduciton in the combined triple endpoints of cardiac death, acute myocardial infarction or development of heart failure (p = 0.046). Controlling for baseline LVEF and assignment to ramipril using Cox regression analysis, increases in EDVI and ESVI up to 3 months predicted an increased risk of future clinical events.

Ramipril reduces the postoperative increase in LV volumes in patients with moderate LV dysfunction and no clinical heart failure undergoing invasive revascularization for chronic stable angina.

Interpretation:

The degree to which LV volumes (and LVEF) change after revascularization in patients with impaired LV function is likely dependent upon the amount of hibernating myocardium revascularized. This study does not provide any information as to the difference in the amount of hibernating myocardium in the ramipril and placebo groups. Without this information, it is difficult to attribute the decreased LV volumes in ramipril group solely to the effect of the drug. Nevertheless, if randomization was effective in this regard, then the results are compelling.

References:

1. Kjoller-Hansen L, Steffensen R, Grande P. J Am Coll Cardiol 2001;37:1214-20.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Stable Ischemic Heart Disease, Echocardiography/Ultrasound, Chronic Angina

Keywords: Myocardial Infarction, Angina, Stable, Stroke Volume, Myocardium, Ramipril, Ventricular Dysfunction, Left, Regression Analysis, Echocardiography


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