Short QT Interval and Atrial Fibrillation in Patients Without Structural Heart Disease

baseline characteristics, event-free patients were younger (54 vs. 61 years, p 0.0001), had a lower functional class (New York Heart Association functional class I to II 97% vs. 87%, p 0.003), and had a higher ejection fraction (32% vs. 29%, p 0.002) at randomization. Event-free patients were also more likely to receive in-trial enalapril therapy than placebo (38 [62%] vs. 173 [48%], p 0.04). Our data indicated that early enalapril therapy reduced death and serious CV morbid events at 15 years in the Belgian SOLVD cohort. Specifically, at the end of this extended follow-up, a significant risk reduction in mortality was observed among patients treated early with enalapril compared with placebo, confirming our previous findings in the X-SOLVD trial. One mechanism that could explain these clinical benefits is the beneficial effect of enalapril on left ventricular remodeling and diastolic properties (5). Furthermore, prevention of early nonfatal cardiac ischemic events by enalapril during in-trial treatment (3) may lead to a late benefit in mortality. The original SOLVD data showed that enalapril reduced the incidence of cardiac ischemic events. The present study extended this finding by showing that the risk of death or nonfatal cardiac ischemic events remained significantly lower in the early enalapril group than in the delayed group. This suggests that earlier treatment initiation may confer long-term protection against atherosclerotic complications by a sustained beneficial effect on plaque stability and vascular remodeling (3,6). Moreover, our data suggested that on the event-free patients, middle-aged asymptomatic subjects derived the most protection from early enalapril therapy. This observation confirms the need to initiate enalapril without delay in patients with reduced ejection fractions, even in the absence of symptoms. However, we could not exclude that genetic variations might also explain this excellent long-term evolution. In conclusion, in the 15-year follow-up of the Belgian SOLVD cohort, early enalapril therapy prevented late deaths and serious CV morbid events beyond the original trial period. Our data also refuted the suggestion that ACE inhibitors in patients with asymptomatic or minimally symptomatic ventricular dysfunction would not confer any long-term benefit except for masking the development of heart failure. Our study showed the importance of starting ACE inhibitor therapy as early as possible in patients with left ventricular systolic dysfunction to avoid any delay resulting in any significant loss of benefits years later.