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The conclusions of your recent editorial commentary (1)on a meta-analysis (2)of the trials of angiotensin-converting enzyme (ACE) inhibitors in acute myocardial infarction (MI) go far beyond the randomized evidence and could well be mistaken. As treatments for acute MI, aspirin substantially improves survival (3)and ACE inhibitors moderately improve survival (2,4). The trials of aspirin were done at a time when ACE inhibitors were not routinely used in acute MI, and demonstrated the substantial effectiveness of aspirin. The trials of ACE inhibitors were done more recently, at a time when aspirin was already widely used in acute MI, and the meta-analysis of their results showed that the addition of ACE inhibitors produced a small but significant additional benefit: that is, that aspirin + ACE inhibitors produce slightly better survival than aspirin alone (2). It was concluded that aspirin is of value in the treatment of acute MI, and that the combination of aspirin + ACE inhibitors is slightly but significantly better than aspirin alone. A similar conclusion was suggested by meta-analyses of the trials of long-term aspirin therapy (3)and of the trials of long-term ACE inhibitor therapy (5); aspirin is of value, but the combination of aspirin + ACE inhibitors is somewhat better than aspirin alone.
In the trials of ACE inhibitors both during and after MI, there was no significant interaction between the presence of aspirin and the efficacy of ACE inhibitors (2,5), and it was a bizarre non-sequiturfor your editorial commentary on these trials convolutedly to conclude that many patients receiving long-term ACE inhibitors should be denied the proven benefits of long-term aspirin therapy in exchange for the less clearly proven benefits of other antiplatelet agents.
- American College of Cardiology
- Hall D.
- Latini R.,
- Tognoni G.,
- Maggioni A.P.,
- et al.
- Antiplatelet Trialists’ Collaboration
- ACE Inhibitor Myocardial Infarction Collaborative Group