OBJECTIVES: Pretreatment with angiotensin-converting enzyme inhibitors (ACEI) has shown promising results in decreasing the incidence and the severity of ischemic stroke in populations at risk, and in improving ischemic stroke outcomes. The aims of this study were to investigate the impact of ACEI use before ischemic stroke onset on in-hospital mortality and to identify the independent predictors of in-hospital mortality among ischemic stroke patients.  METHODS: It is a retrospective cohort study of all acute ischemic stroke patients admitted to a 1200-bed hospital located in northern Malaysia from June 1, 2008 to November 30, 2008. Data were collected from medical records and included demographic information, diagnostic information, risk factors, previous ACEI use and vital discharge status. SPSS version 15 was used for data analysis.   RESULTS: Overall, 327 acute ischemic stroke patients were studied, of which 119 (36.4%) had documented previous ACEI use. During the study period, 52 (15.9%) of the acute ischemic stroke patients died in hospital. In-hospital mortality was significantly lower among patients who were on ACEI before the attack (p = 0.002). The independent predictors for in-hospital mortality among ischemic stroke patients were the presence of diabetes mellitus (p = 0.023), renal impairment (p <0.001) and heart failure (p = 0.007). Moreover, prior use of ACEI was an independent predictor for survival after ischemic stroke attack (p <0.001)  CONCLUSIONS: This study provides evidence that the prophylactic administration of ACEI is a potential life-saving strategy. Furthermore, knowledge of in-hospital mortality predictors is necessary to improve survival rate after acute ischemic stroke attack.