[Remodeling with angiotensin-converting enzyme inhibitors: from GISSI to PREAMI].

The use of angiotensin-converting enzyme (ACE) inhibitors early after acute myocardial infarction has been demonstrated to be useful for the primary prevention of ventricular remodeling. This treatment has also shown significant and early beneficial effects on mortality, whereas the observed effect in terms of prevention of absolute volume increase was definitely small, and mainly in large infarcts. These results suggest that other effects of ACE-inhibition could contribute to the observed improvement in clinical endpoints. All this has increased the interest in pathophysiologic studies on cardiac remodeling, like the GISSI-3 Echo Substudy, which has shown the complexity and heterogeneity of the phenomenon. In this context comorbidity and mortality are increasing with age, but information on remodeling in the elderly with preserved ventricular function is still lacking. Post-infarction patients > 65 years of age with preserved ventricular function (ejection fraction > 40% by echocardiography) have then been randomized into the Perindopril and Remodelling in the Elderly with Acute Myocardial Infarction (PREAMI) trial. Although mortality and hospitalization for congestive heart failure were not affected significantly by 1-year 8 mg/day of perindopril treatment, a significant beneficial treatment-related effect was observed on left ventricular remodeling. These results suggest the great need for analyzing the heterogeneity of remodeling in the context of different populations with myocardial infarction. This could lead to more individualized and aggressive diagnostic, prognostic and therapeutic approaches even in patients at low risk with a small myocardial infarction.