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Am Fam Physician. 2005;71(10):2000

When taken after an acute myocardial infarction, angiotensin-converting enzyme (ACE) inhibitors improve survival and reduce the risk of recurrence. This has been thought to be a class effect––i.e., all drugs in the class have the same beneficial outcomes. Because different ACE inhibitors vary in structure and potency, they may not be equally effective. Pilote and associates examined the one-year mortality rate of various ACE inhibitors when given to older persons after a first acute myocardial infarction.

A chart review was used to identify patients 65 years or older who filled at least one prescription for an ACE inhibitor within 30 days of discharge following an acute myocardial infarction. A total of 7,512 patients were selected and were grouped by ACE inhibitor. Patients who switched prescriptions during the first year were excluded. Enalapril was the most common prescription, followed by lisinopril.

Patients taking enalapril, fosinopril, captopril, or quinapril had higher mortality rates than those taking ramipril. No significant difference was shown between ramipril and lisnopril or perindopril. Readmissions for unstable angina and recurrent myocardial infarction were similar across all treatment groups.

The authors conclude that there is variation among ACE inhibitors, and that the one-year mortality rate is significantly lower in older persons who take ramipril after a first acute myocardial infarction than in those taking other ACE inhibitors. It is unclear what mechanism is responsible for this difference. More studies are needed to confirm these results.

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