Secondary prevention of myocardial infarction: Role of β-adrenergic blockers and angiotensin-converting enzyme inhibitors,

β-Blockers reduce cardiovascular death and reinfarction in patients with a history of myocardial infarction (MI), and angiotensin-converting enzyme (ACE) inhibitors provide an overall survival benefit in patients with signs or symptoms of left ventricular (LV) dysfunction and a history of acute MI. Despite this, these agents remain underused in clinical practice. Appropriate patient selection in standard clinical practice should be encouraged in order to achieve a mortality rate reduction comparable to that seen in clinical trials. It appears from the findings of recent studies that the greatest benefit from β-blocker therapy is achieved in patients who are more than 60 years of age and in patients at moderate or high risk for reinfarction and death (eg, patients with LV dysfunction or arrhythmias or both). Patients with class I-IV heart failure treated with ACE inhibitors have fewer recurrent infarctions, a lower incidence of severe congestive heart failure, and a reduced incidence of total cardiovascular death and sudden cardiac death. In addition to the studies completed in patients with MI, there are ongoing studies evaluating whether or not ACE inhibitors can reduce myocardial ischemic events in patients without a prior infarction who have coronary artery disease or hypertension and preserved LV function. There is also growing evidence that concomitant therapy with a β-blocker and an ACE inhibitor may reduce mortality rates beyond that observed with ACE inhibitors alone in survivors of MI who have LV dysfunction. (Am Heart J 1999;137:S25-S34.)