The prognostic value of predischarge quantitative two-dimensional echocardiographic measurements and the effects of early lisinopril treatment on left ventricular structure and function after acute myocardial infarction in the GISSI-3 Trial

• Published in: European heart journal Vol. 17; no. 11; pp. 1646 - 1656
• Main Authors: Nicolosi, G. L., Latini, R., Marino, P., Maggioni, A. P., Barlera, S., Franzosi, M. G., Geraci, E., Santoro, L., Tavazzi, L., Tognoni, G., Vecchio, C., Volpi, A.
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01.11.1996
• Subjects: 2-D echocardiography; ACE inhibition; Biological and medical sciences; Cardiology. Vascular system; Coronary heart disease; Heart; left ventricular remodelling; Medical sciences; Myocardial infarction; Sonography; Human; Echocardiography; Lisinopril; Prognosis; Infarct; Enzyme; Enzyme inhibitor; Cardiovascular disease; Exploration; Coronary heart disease; Left ventricle; Peptidases; Chemotherapy; Treatment; Peptidyl-dipeptidase A; Myocardium; Hydrolases; Peptidyl-dipeptidases; Structure
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/oxfordjournals.eurheartj.a014747

Background Left ventricular dilatation and a low ejection fraction after acute myocardial infarction are independent indicators of a poor prognosis. ACE inhibitors have been shown to decrease left ventricular dilatation after myocardial infarction. In the GISSI-3 trial, patients were randomlyassigned, within 24 h of onset of myocardial infarction symptoms, to 6 weeks of treatment with lisinopril, nitroglycerin, both or neither, in an open, 2 × 2 factorial design. The study showed that early treatment in relatively unselected patients with lisinopril decreases mortality at 6 weeks and severe left ventricular dysfunction. We assessed (1) the prognostic value of pre-discharge 2-D echocardiographic variables, and (2) the effects of lisinopril on the progression of left ventricular dilatation. Methods and results 2-D echocardiograms were available pre-discharge in 8619 GISSI-3 trial patients discharged alive. In 6405 of these patients, a 2-D echocardiographic study was also available at 6 weeks, and at 6 months. Pre-discharge end-diastolic and end-systolic volumes, and ejection fraction predicted 6-month mortality and non-fatal clinical congestive heart failure (P<0.01). The increase in left ventricular volumes over time was significantly reduced by 6 weeks' lisinopril treatment in patients with wall motion asynergy pre-discharge of ≥27%. Patients with wall motion asynergy <27% showed no dilatation and lisinopril did not affect volumes at 6 months. Patients randomized to lisinopril also had smaller volumes after withdrawal of treatment at 6 weeks. Lisinopril did not affect left ventricular ejection fraction. Conclusions 2-D echocardiography independently contributes to pre-discharge risk stratification in terms of 6-month mortality and clinical heart failure after myocardial infarction, and early, short-term treatment with lisinopril in unselected myocardial infarction patients attenuates left ventricular dilatation; an effect evident in patients with larger infarcts. These results probably only partly explain the effect of lisinopril on total mortality concentrated in the first week after infarction.