[Prognostic value of noninvasive markers of coronary reperfusion compared to TIMI 3 flow in patients treated with primary angioplasty]. / Valor pronóstico de marcadores no invasivos de reperfusión coronaria frente a flujo TIMI 3 en pacientes tratados con angioplastia primaria.

INTRODUCTION AND OBJECTIVES: The aim of this study was to compare the prognostic value of TIMI 3 flow versus noninvasive markers of coronary artery reperfusion on the outcome of patients with a recent acute myocardial infarction (AMI) treated with primary angioplasty. PATIENTS AND METHOD We analyzed 172 consecutive patients with AMI and ST-segment elevation, who were treated with primary angioplasty within 12 hours of admission. Mean age was 6113 years, 77% were men, and 56% had a history of previous AMI. RESULTS: In-hospital mortality was 3.6%; 16.6% developed heart failure, and 11.1% had complex arrhythmias during their hospital stay. The noninvasive criterion for successful reperfusion was the presence of two or more markers of reperfusion based on ECG changes or CK levels after angioplasty. Reperfusion was successful in 87.7% of the patients, and TIMI 3 flow was achieved in 87%. There was no significant concordance between the two methods (kappa index = 0.012). Multivariate analysis showed that both successful reperfusion (OR=0.028; 95% CI, 0.003-0.268) and TIMI 3 flow (OR=0.104; 95% CI, 0.019-0.563) were protective for in-hospital mortality. However, in the multivariate analysis only successful reperfusion was a protective factor for heart failure and complex arrhythmias. CONCLUSION: Our findings confirm that both TIMI 3 flow and successful coronary reperfusion evaluated noninvasively show independent prognostic value in patients with AMI treated with primary angioplasty. Noninvasive markers of coronary reperfusion should be used as complementary to angiography in these patients.

Valor pronóstico de marcadores no invasivos de reperfusión coronaria frente a flujo TIMI 3 en pacientes tratados con angioplastia primaria / Prognostic value of noninvasive markers of coronary reperfusion compared to TIMI 3 flow in patients treated with primary angioplasty

Introducción y objetivos. La angioplastia primaria ha resultado ser el tratamiento más eficaz para pacientes con infarto agudo de miocardio (IAM). Tanto la obtención de un flujo coronario óptimo, grado TIMI 3, como la asociación de indicadores no invasivos de reperfusión coronaria han demostrado ser métodos útiles para predecir el pronóstico inmediato y a medio plazo de pacientes con IAM tratados con trombólisis o angioplastia primaria. El objetivo es comparar el valor pronóstico del flujo TIMI 3 con la asociación de indicadores no invasivos de reperfusión coronaria (disminución del supradesnivel del segmento ST > 50 por ciento a los 90 min, inversión de la onda T dentro de las 24 h y elevación máxima de la creatincinasa [CK] 70 por ciento, valor máximo de CK) demostró que tanto la reperfusión exitosa como el flujo TIMI 3 resultaron ser protectores frente a la mortalidad intrahospitalaria (odds ratio [OR] = 0,028; intervalo de confianza [IC] del 95 por ciento, 0,003-0,268, y OR = 0,104; IC del 95 por ciento, 0,019-0,563, respectivamente). Sin embargo, sólo la reperfusión exitosa resultó ser protectora frente a la insuficiencia cardíaca y las arritmias complejas en la evolución intrahospitalaria y en la mortalidad a medio plazo al ajustar por ambos criterios en el análisis multivariado. Conclusión. Se confirma que tanto el flujo TIMI 3 como la reperfusión coronaria exitosa evaluada a través de indicadores no invasivos tienen un valor pronóstico independiente en pacientes con IAM tratados con angioplastia primaria. Sin embargo, la reperfusión coronaria exitosa resultó ser un indicador de pronóstico independiente para la mortalidad intrahospitalaria y a medio plazo, el desarrollo de insuficiencia cardíaca y arritmias complejas. Los indicadores no invasivos de reperfusión coronaria debieran emplearse en forma complementaria a la angiografía en estos pacientes (AU)

Hipercoagulabilidad en fibrilación auricular y su relación con factores de riesgo para embolia sistémica / Hypercoagulable state in atrial fibrillation and its relationship with risk factors for systemic embolism

Background: Atrial fibrillation is associated to a high risk of systemic embolism and to hypercoagulability. Aim: To evaluate the activation of the coagulation cascade through determinations of the thrombin-antithrombin complex in patients with atrial fibrillation and to correlate this data with the clinical and echocardiographic risk factors for systemic embolism. Patients and Methods: In 53 patients with atrial fibrillation plasma levels of the thrombin-antithrombin complex were determined on admission to a coronary care unit and 30 days later. Using a univariate and multiple regression analysis, the association basal thrombin-antithrombin with the duration of the arrhythmia, age over 70 years, previous use of antiplatelet agents, history of hypertension, mitral valve disease, diabetes, heart failure, previous systemic embolism, left atrial diameter and the presence of spontaneous contrast echo or thrombus in the left atrial appendage, was studied. Results: Basal thrombin-antithrombin values were 40.1ñ69 mg/L (Median 8.34 [3.0-47.5]) compared to 2.7ñ3.3 mg/L in healthy controls (p <0.001). No significant correlation was found between activation of the coagulation cascade and risk factors for systemic embolism. There were no significant differences in thrombin-antithrombin values between patients with chronic or paroxysmal atrial fibrillation (29.5ñ43 mg/L and 49.4ñ83 mg/L respectively). Mean thrombin-antithrombin values in patients under antiplatelet agents were lower than in those without treatment (17.3ñ43 vs 66.8ñ127 mg/L; p=0.018). Conclusions: The activation of the coagulation cascade in patients with atrial fibrillation was confirmed. However, no association of this activation with well known clinical and echocardiographic risk factors for systemic embolism, was found. Previous antiplatelet treatment prevented a higher activation of the coagulation cascade

Reducción de la mortalidad por infarto del miocardio en hospitales chilenos / Reduction of acute myocardial infarction mortality in Chilean hospitals

Background: The characteristics of patients with acute myocardial infarction (MI) admitted to 37 Chilean hospitals (GEMI Registry Group), have been analyzed in the periods 1993-1995 and 1997-1998. Aim: To report the changes in hospital mortality between these 2 periods, with a particular emphasis on the impact of treatment. Patients and methods: Between 1993-1995 we collected information from 2,957 patients and between 1997-1998 we registered 1,981 patients with MI. Analysis of the changes in mortality between periods was adjusted by demographic variables, coronary risk factors, MI location, Killip class on admission and the different therapeutic strategies utilized. The effects of different treatments on hospital mortality were adjusted by the previously determined mortality risk variables. Results: Hospital mortality decreased from 13.3 percent to 10.8 percent between both periods (Odds Ratio (OR) 0.78, confidence intervals (95 percent) (CI) 0.65-0.93). A significant reduction in mortality was observed among patients below 60 years of age, in men, in diabetics and in subjects with an infarction classified as Killip class over II. The use of beta blockers (OR 0.65, CI 0.42-0.99) and intravenous nitrates (OR 0.78, CI 0.61-0.99) and the lower use of calcium channel blockers (OR 0.72, CI 0.60-0.87) were significantly associated with a lower mortality. The administration of angiotensin converting enzyme inhibitors was associated with a 29.3 percent mortality reduction (OR 0.69, CI 0.47-1.02). Conclusions: There has been a significant reduction in the mortality rate for MI in Chilean hospitals during the 2 registry periods analyzed, which was significant among some high risk patients and was related to treatment changes, according to evidence based guidelines

Experiencia de 36 años con marcapasos implantables: un análisis histórico / A 36 year experience with implantable pacemakers

Background: The implantation of pacemakers improves cardiac function and quality of life, in particular with dual chamber DDD and DDDR modes. Aim: To evaluate our clinical experience and results on pacemaker implantation, from 1963 to 1998. Material and methods: Computerized data collected from 2,445 consecutive paced patients was reviewed. A total of 3,554 operative procedures were performed, including 412 procedures for complications and 697 pacemaker replacement. Patient survival was determined from clinical records, inquiry to pacemaker manufacturers and death certificates from Servicio de Registro Civil e Identificaci-n de Chile (Chilean Civil and Identification Registry). Results: Use of dual chamber (DDD and DDDR) pacemakers increased progressively up to 74 percent from 1988 to 1998. Complication rate was 42 percent in the 1963-1976 study period, it decreased to 10.6 percent in the 1977-1987 study period, and to 5.6 percent by 1988-1998. Only two patients died during surgery in the study period (0.08 percent). In the 1977-1987 period, pacemakers lasted 10.6 years. Survival rates were 52 percent at ten years, 33 percent at 15 years, and 21 percent at 20 years, with a median survival of 11.7 years, and 7.24 years in patients over 80 years old. Conclusions: Transvenous permanent pacing can be accomplished today with a low complication rate, mainly due to better technology and surgical procedures

Variantes genéticas de los receptores adrenérgicos y enfermedades cardiovasculares / Genetic variants of the adrenergic receptors and cardiovascular diseases

El proyecto Genoma Humano ha logrado descifrar la secuencia completa del genoma, aportando una herramienta única para el estudio de la genética humana. Sin embargo, se ha observado cada vez más frecuentemente la aparición de variantes genéticas, o polimorfismos, en cada uno de los genes estudiados. Como reguladores claves de diversos sistemas, los receptores adrenérgicos proveen un sistema único para explorar una posible relación entre los polimorfismos del receptor y la respuesta a fármacos y susceptibilidad o progresión de las enfermedades cardiovasculares. Los adrenoreceptores pertenecen la superfamilia de los receptores con siete dominios de transmembrana que producen su efecto a través del acoplamiento con distintas proteínas G. Hasta la fecha se han identificado varios subtipos de adrenoreceptores alfa sub 1A, alfa sub 1B, alfa sub 1D, alfa sub 2A, alfa sub 2B, alfa sub 2C ß1, ß2, ß3 y ß4. Este artículo provee una visión general de los polimorfismos existentes en los receptores adrenérgicos y su relación con las enfermedades cardiovasculares

Cambios en los patrones de prescripción de medicamentos en el infarto agudo del miocardio: comparación de dos períodos / Changes in pharmacotherapy for acute myocardial infarction: comparison of 2 periods

Background: Pharmacotherapy of Chilean patients with acute myocardial infarction has been recorded in 37 hospitals since 1993. Aim: to compare pharmacotherapy for acute myocardial infarction in the period 1993 to 1995 with the period 1997-1998. Patients and methods: Drug prescription during hospital stay was recorded in 2957 patients admitted to Chilean hospitals with an acute myocardial infarction in the period 1993-1995 and compared with that of 1981 subjects admitted in the period 1997-1998. Results: When compared with the former period, in the lapse 1997-1998 there was an increase in the frequency of prescription of aspirin (93 and 96.1 percent respectively) ß blockers (37 and 55.2 percent respectively) and angiotensin converting enzyme inhibitors (32 and 53 percent). The prescription of thrombolytic therapy did not change (33 and 33.7 percent respectively). There was a reduction in the prescription of calcium antagonists and antiarrhythmic drugs. Conclusions: During the period 1997-1998, the prescription of drugs with a potential to reduce the mortality of acute myocardial infarction, increased. The diffusion of guidelines for the management of this disease may have influenced this change

La hiperuricemia es un marcador del umbral anaeróbico en la insuficiencia cardíaca crónica / Hyperuricemia is a marker for anaerobic threshold in chronic cardiac failure

Background: Patients with chronic cardiac failure often have elevated plasma uric acid levels, that are associated to a dismal prognosis. Aim: To investigate possible metabolic mechanisms to explain elevated uric acid levels in these patients. Patients and methods: Eighteen patients with chronic cardiac failure aged 61 ñ 10 years old, without gout or renal failure and not using high doses of diuretics (equal or less than 80 mg/day furosemide or 50 mg/day hydrochlorothiazide) were studied. Plasma uric acid levels were correlated with anaerobic threshold, maximal oxygen uptake, plasma noradrenaline and creatinine and left ventricular ejection fraction, measured radioisotopically. Results: Mean maximal oxygen uptake was 16.6 ñ 4.2 ml/kg/min. There was a negative correlation between uric acid levels and maximal oxygen uptake or maximal oxygen uptake/body surface area (r=0.521 and -0.533 respectively, p<0.05). Patients with uric acid levels over 7 mg/dl had a lower anaerobic threshold than patients with lower levels (9.81 ñ 2.41 and 13.08 ñ 3.28 ml/kg/min respectively, p<0.05). No significant differences in maximal oxygen uptake were observed in these two groups of patients (15.5 ñ 4.24 and 18.08 ñ 3.86 ml/kg/min respectively). Uric acid levels did not correlate with plasma noradrenaline, creatinine or lefi ventricular ejection fraction. Conclusions: These results suggest that a defect in cellular oxygenation contributes to the elevation of plasma uric acid levels in patients with chronic cardiac failure

Entrenamiento selectivo de los músculos respiratorios en pacientes con insuficiencia cardíaca crónica / Selective training of respiratory muscles in patients with chronic heart failure

Background: Patients with chronic heart failure have a lower inspiratory muscle strength and fatigue endurance. Aim: To assess the effects of selective training of respiratory muscles in patients with heart failure. Patients and methods : Twenty patients with stable chronic heart failure, aged 58.3 ñ 3 years with an ejection fraction of 28 ñ 9 percent, were subjected to respiratory muscle training with threshold valves. The load was fixed in 30 percent of maximal inspiratory pressure (PImax) in 11 and in 10 percent of PImax in nine. Two sessions of 15 minutes, 6 days per week, during 6 weeks were done. Degree of dyspnea (Mahler score), maximal oxygen uptake, distance walked in 6 minutes, respiratory muscle function and left ventricular ejection fraction were measured before and after training. Results: Both training loads were associated to an improvement in dyspnea (+2.7 ñ 1.8 and +2.8 ñ 1.8 score points with 30 percent Plmax and 10 percent PImax respectively), maximal oxygen uptake (from 19 ñ 3 to 21.6 ñ 5 and from 16 ñ 5 to 18.6 ñ 7 ml/kg/min with 30 percent PImax and 10 percent PImax respectively, p< 0.05), PImax (from 78 ñ 22 to 99 ñ 22 and from 72 ñ 34 to 82.3 cm H20 with 30 percent Plmax and 10 percent PImax respectively), sustained PImax (from 63 ñ 18 to 90 ñ 22 and from 58 ñ 3 to 69 ñ 3 cm H20 with 30 percent PImax and 10 percent PImax respectively), and maximal sustained load (from 120 ñ 67 to 195 ñ 47 and from 139 ñ 120 to 192 ñ 154 g with 30 percent PImax and 10 percent PImax respectively). The distance walked in 6 min only increased in subjects trained at 30 percent PImax (from 451 ñ 78 to 486 ñ 68 m). Conclusions: Selective training of respiratory muscles results in a functional improvement of patients with chronic heart failure

Solución GIK en el infarto agudo al miocardio: el resurgimiento de una antigua terapia / Glucose-insulin-K solution for acute myocardial infarction: rebirth of an old form of therapy

La terapia con solución de glucosa insulina y potasio en el infarto o solución GIK fue inicialmente utilizada por Sodi-Pallares. Desde entonces muchos trabajos con esta solución han sido publicados con resultados disímiles. Sin embargo el resultado de un meta-análisis reciente, que incluye sólo trabajos randomizados con dosis adecuadas de GIK, parece confirmar la disminución de la mortalidad asociada a solución GIK. Para comprender mejor los fundamentos y posibles mecanismos de beneficio con el empleo de la solución GIK en el infarto del miocardio, revisaremos primero el metabolismo miocárdico normal y en condiciones de isquemia, luego el daño por reperfusión post infarto y los efectos de la solución GIK en el miocardio. Por último, analizaremos las experiencias clínicas publicadas con esta terapia

Apnea del sueño en la insuficiencia cardíaca estable: factores predisponentes / Sleep apnea in patients with stable congestive heart failure: predisposing factors

En los pacientes con insuficiencia cardíaca crónica(ICC) se ha descrito una falta prevalencia de alteraciones ventilatorias e hipoxemia durante el sueño. Para evaluar los factores asociados a su incidencia estudiamos con polisomnografía nocturna a 14 pacientes con ICC estable y los resultados se correlacionaron con la edad, capacidad aeróbica, función ventricular y distintos parámetros de ventilación, congestión y perfusión periférica. La etiología de la ICC era isquémica en 8 e idiopática en 6 pacientes. El estudio respiratorio durante el sueño resultó anormal en 6 pacientes (43 por ciento). Ellos presentaron 37 +18 episodios de apnea/hipopnea por hora, con predomio de apneas de tipo central. En análisis univariado, resultaron predictores de apnea del sueño la menor capacidad funcional y consumo de 02 máximo, la elevación del ácido, láctico arterial y de la uricemia, y la disminución de la PaC02 en vigilia. La función ventricular izquierda y la congestión pulmonar o sistémica, no fueron predictores de apnea del sueño. Conclusión: se corrobora una alta incidencia de apnea del sueño en la ICC y de acuerdo a nuestros datos se puede identificar a los pacientes con mayor riesgo usando criterios clínicos y de laboratorio sencillos

Tratamiento de la fibrilación auricular: un dilema permanente / Treatment of atrial fibrillation: a persistent dilema

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Increased life expectancy will result in a higher prevalence of AF. Treatment of AF constitutes a persistent medical dilemma. Different multicenter trials have confirmed that oral anticoagulant therapy is the best choice for the prevention of systemic embolism. It must be recognized, however, that the incidence of systemic embolism in patients with AF varies according to the presence and type of underlying heart disease. Advanced age increases the risk of emboli in patients with AF. At the same time, older patients have a higher risk of hemorrhage when treated with oral anticoagulants. Thus, careful titrated individual oral anticoagulant therapy targeted to a safe and effective INR must be considered in patients with AF. Another dilemma in AF patients is the convenience of restoring sinus rhythm and indicating permanent antiarrhythmic therapy versus the alternative of heart rate control plus oral anticoagulants. Several multicenter trials now in progress have addressed this issue and most likely will answer these questions. Identification of patients with paroxysmal AF and risk of systemic embolism constitutes another dilemma, since only a small proportion of these patients evolve to chronic arrhythmia. Advanced age, history of hypertension and left atrial enlargement in 2D Echo are well recognized risk factors for embolism in patients with non valvular paroxysmal AF. A history of previous embolism constitutes another risk factor and supports the hypothesis that AF may activate systemic coagulation factors and left atrial thrombus formation in some patients

Ritmo cardíaco y embolias sistémicas en la evolución alejada de pacientes con fibrilación auricular paroxística no valvular / Cardiac rhythm and systemic emboli during long term follow up of patients with non-valvular paroxysmal atrial fibrillation

Background: Paroxysmal atrial fibrillation may predispose to systemic embolism. There is little information about the evolution of cardiac rhythm and the occurrence of new embolic events in these patients. Aim: To report the results of a long term follow up of patients with paroxysmal atrial fibrillation. Patients and methods: Patients consulting for non valvular paroxysmal atrial fibrillation were followed for a mean period of 5 years. An EKG, 2D echocardiogram and brain CT scans were performed on admission and at the end of the follow up period to all patients. Results: Sixty eight patients aged 65 ñ 1.5 years were studied. Thirty two had an idiopathic atrial fibrillation, 28 had a history of mild hypertension and 8 had a history of coronary artery disease. Evidence of systemic emboli was found in 17 patients at entry (to the brain in 14 patients). During the follow up 87 per cent of patients required antiarrhythmics, 27 per cent were anticoagulated and 28 per cent received aspirin. Five patients had new embolic episodes. Of these, four had a history of prior embolism. Forty one percent of patients continued in sinus rhythm and remained asymptomatic, 32 per cent had at least one recurrence of paroxysmal atrial fibrillation and nine patients evolved to chronic atrial fibrillation. Five patients required a permanent pacemaker due to symptomatic bradycardia. Conclusions: Most patients with non valvular paroxysmal atrial fibrillation remain in sinus rhythm but one third have recurrences of the arrhythmia. A main risk factor for embolism is the history of previous embolic episodes

Heparina de bajo peso molecular versus heparina no fraccionada en el tratamiento de la angina inestable / Comparison of low molecular weight heparin and unfractionated heparin in the treatment of unstable angina

Background: Low molecular weight hepartin can be administered by the subcutaneous route and has stable and prolonged antithrombotic effect. These features have prompted clinical essays about its use as an alternative to unfractional heparin in the treatmen of unstable angina. Aim: To compare the clinical effects of low molecular weight heparin and unfractionated conventional heparin in patients with unstable angina or non Q infarction. Patients and methods: Seventy patients (47 male) admitted to the hospital with the diagnosis of unstable angina or non Q acute myocardial infarction were randomly assigned to receive unfractionated intravenous heparin or subcutaneous low molecular weight heparin bid. All received aspirin po and iv nitroglycerin. The incidence of recurrent angina, acute myocardial infarction or a need for emergency surgical revascularization during hospital stay were assessed in both groups. Results: Compared to patients with low molecular weight heparin, patients receiving unfractionated heparin had a higher incidence of recurrent resting angina (23 and 47.75 percent respectively, p< 0.04) and higher need for emergency surgical revascularization (3.3 and 17.5 percent respectively, p< 0.06). Patients treated with unfractionated conventional heparin had a 3 times higher risk of having an adverse cardiovascular event than patients receiving low molecular weight heparin (O.R. 0.33, confidence intervals 0.11-0.58). Conclusions: Low molecular weight heparin is superior to unfractionated conventional heparin in the treatment of unstable angina and non Q acute myocardial infarction

Empleo de agentes trombolíticos durante la gestación / Utility of thrombolytic agents during the gestation

Los agentes trombolíticos son efectivos en disolver trombos intravasculares. Su seguridad durante la gestación sigue siendo objeto de debate, por lo que su uso se reserva para los casos de tromboembolismo hemodinámicamente significativos o trombólisis durante la gestación. Una paciente presentó un tromboembolismo pulmonar masivo secundario a trombosis de extremidades inferiores y la otra presentó dos episodios de trombosis de válvula protésica cardíaca. Los agentes empleados fueron urokinasa en la primera paciente y estreptokinasa y activador del plasminógeno tPA (alteplasa) en dos oportunidades en la segunda. Se discute su empleo, riesgos durante la gestación, y resultado perinatal. Este es el primer reporte nacional y uno de los pocos internacionales del uso del tPA durante la gestación

Cambios morfofuncionales precoces en el infarto del miocardio experimental: efecto de la inhibición de la enzima convertidora de angiotensina / Morphofunctional early changes in myocardial experimental infarction: effect of angiotensin converting enzyme inhibition

El presente estudio tuvo como objetivo caracterizar el efecto de un inhibidor de la enzima convertidora de angiotensina (ECA) sobre los cambios estructurales y funcionales miocárdicos post infarto al miocardio (IAM) experimental en ratas. Se evaluaron los cambios morfológicos y las propiedades mecánicas del miocardio en el corazón aislado perfundido. El estudio se efectuó en dos grupos experimentales, uno tratado con placebo (n = 22) y otro administrando el inhibidor de ECA ramipril (10 mg/l en agua a beber, n = 15) durante 45 días. Al comparar con el grupo placebo, en el grupo tratado con ramipril observamos menor relación peso ventricular derecho/peso corporal (0.83 ñ 0.38 vs 1.16 ñ 0.31, respectivamente, p < 0.05), mayor espesor de la pared ventricular izquierda en la zona de la cicatriz del infarto (0.89 ñ 0.58 vs 0.57 ñ 0.28 mm, respectivamente, p < 0.05) y una menor pendiente de la relación tensión-elongación diastólica (106.8 ñ 0.9 vs 13.7 ñ 1.2 g/cm², respectivamente, p < 0.05). El porcentaje del área ocupado por el infarto fue 39.4 ñ 12.1 en el grupo placebo y 34.8 ñ 13.4 en el grupo tratado con ramipril (ns). En conclusión, el inhibidor de la ECA ramipril, a las dosis utilizadas durante 6 semanas en ratas con infarto al miocardio experimental, demostró prevenir el desarrollo de hipertrofia ventricular derecha, con el desarrollo de una cicatriz de mayor grosor y un VI menos rígido con una tendencia a un menor tamaño del infarto que en las ratas no tratadas.Estos efectos morfofuncionales podrían explicar en parte el efecto benéfico de los inhibidores de la ECA en el curso clínico del IAM

Ramipril vs espironolactona en el remodelamiento ventricular izquierdo post-infarto: estudio randomizado y doble ciego / Ramipril vs spironolactone in the left ventricular remodeling after infarction: randomized and double blind study

Patients and methods: Patients hospitalized for a first episode of acute myocardial infartion were blindly and randomly assigned to receive ramipril (2.5 mg bid), spironolactone (25 mg bid) or placebo. Ejection fraction, left ventricular en diastolic and end systolic volumes were measured by multigated radionuclide angiography, at baseline and after six months of treatment. Results: Twenty four patients were assigned to placebo, 31 to ramipril and 23 to spironolactone. Age, gender; Killip class, treatment with thrombolytics, revascularization procedures and use of additional medications were similar in the three groups. After six months of treatment, efection fraction increased from 34,5 ñ 2,3 to 4,2 ñ 2,4 percent in patients on ramipril, from 32,6 ñ 2,9 to 36,6 ñ 2,7 percent in patients on spironolactone, and decreased from 37 ñ 3 to 31 ñ 3 in patients on placebo (ANOVA between gropus p < 0.05). Basal end systolic volumen was similar in all three gropus, increased from 43,4 ñ 3,4 to 61,4 ñ 6,0 ml/m2 in patients on placebo and did not change in patients on spironolactone or ramipril (ANOVA p < 0.05). End diastolic volume was also similar in the three groups, increased from 70,6 ñ 4,3 to 92,8 ñ 6,4 ml/m2 in patients on placebo and did no change with the other treatments. Conclusions: Ramipril and spironolactone had similar effects on ventricular remodeling after acute myocardial infaction, suggesting that aldosterone contributes to this phenomenon and that inhibition of its receptor may be as effective as ACE inhibition in its prevention