The comprehensive review of different angiotensin converting enzyme (ACE) inhibitor trial results in patients with acute myocardial infarction presented by Cody1 is timely and excellent. Although the beneficial role of ACE inhibitors in congestive heart failure has now been well established by several major trials, results from some other trials are contradictory.
Why was ACE inhibitor therapy apparently ineffective or even harmful when it was started very early, eg, in the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II)2? Besides the reasons mentioned by Cody, I would like to suggest a couple more. First, the CONSENSUS II investigators used a treatment that might have an adverse effect on early mortality in one subgroup and an inadequate follow-up period to demonstrate a favorable effect in another subgroup. These results are reminiscent of the findings of the Veterans Administration Cooperative Study of the effect of nitroprusside in acute myocardial