Renin-Angiotensin System Blockade and Risk of Heart Failure After Myocardial Infarction Based on Left Ventricular Ejection Fraction: A Retrospective Cohort Study

Protective effect of sacubitril/valsartan in patients with acute myocardial infarction: A meta‑analysis

To evaluate the effects and safety of sacubitril/valsartan in patients with acute myocardial infarction (AMI), a total of four databases, including PubMed, Cochrane Library, Embase and Web of Science, and the ClinicalTrials.gov website were searched. Using a combination of medical subject headings and entry terms, the final search was performed in July 2021. A manual search of cross-references from the original articles was also conducted. The meta-analysis was subsequently performed with Revman 5.3 software and a total of four studies comprising 586 patients were included. The results disclosed a significant reduction in major adverse cardiovascular and cerebrovascular events (MACCEs) [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.30-0.73; P=0.0007], readmission (OR, 0.45; 95% CI, 0.29-0.71; P=0.0006), incidence of acute heart failure (AHF) (OR, 0.45; 95% CI, 0.28-0.71; P=0.0007) and N-terminal pro B-type natriuretic peptide [standardized mean difference (SMD), -0.88; 95% CI, -1.55-(-0.21); P=0.01] in the sacubitril/valsartan group compared with that in the control group, and a random effects model was used to pool these data. No significant differences were identified in the incidence of hypotension (OR, 2.91; 95% CI, 0.55-15.51; P=0.21), adverse events (OR, 2.19; 95% CI, 0.42-11.37; P=0.35), left ventricular ejection fraction (mean difference, 1.96; 95% CI, -0.84-4.76; P=0.17) or soluble suppression of tumorigenesis-2 (SMD, -0.45; 95% CI, -1.62-0.71; P=0.45) according to the random effects model. In conclusion, the present meta-analysis revealed that sacubitril/valsartan was able to effectively reduce the incidence of MACCEs, readmission and AHF in patients with AMI after revascularization without any obvious adverse events.

Prognostic Impacts of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Acute Coronary Syndrome Patients Without Heart Failure

Background: Despite the recommendations from mainstream guidelines, the use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) for acute coronary syndrome (ACS) patients without heart failure (HF) is controversial, as its evidence is lacking in the era of reperfusion and intensive secondary preventions. This study aimed to investigate the impacts of ACEI/ARB on outcomes of ACS patients without HF treated by percutaneous coronary intervention (PCI). Methods: A total of 2,397 non-HF ACS patients treated by PCI were retrospectively recruited. Prognostic impacts of ACEI/ARB were assessed by unadjusted analysis, followed by propensity score matching (PSM) and propensity score matching weight (PSMW) analysis to control the between-group differences. The primary outcome was a composite of all-cause death and recurrent myocardial infarction (MI). Results: Among the included patients, 1,805 (75.3%) were prescribed with ACEI/ARB at discharge. The median follow-up time was 727 (433-2016) days, with 129 (5.4%) primary endpoint events, consisting of 55 (2.3%) cases of all-cause death and 74 (3.1%) cases of recurrent MI. The use of ACEI/ARB was not associated with significant risk reduction of primary endpoint events in unadjusted analysis (hazard ratio [HR]: 0.95, 95% confidence interval [CI]: 0.64-1.39, p = 0.779), PSM analysis (HR: 0.94, 95% CI: 0.60-1.47, p = 0.784), and PSMW analysis (HR: 0.91, 95% CI: 0.55-1.49, p = 0.704). Similar results were observed for secondary outcomes of all-cause death, cardiac death, and recurrent MI. Conclusion: For ACS patients without HF, the use of ACEI/ARB was not associated with lower risk of death or recurrent MI after PCI.

Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in patients with acute decompensated heart failure: a systematic review and meta-analysis

BACKGROUND

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin-receptor blocker (ARB) are cornerstones in the treatment of heart failure with reduced ejection (HFrEF). However, there are limited data on their risk-benefit profile in patients with acute heart failure requiring hospitalizations.

METHODS

We did a meta-analysis pooling data from all studies examining the use of ACEi/ARB in patients hospitalized for heart failure compared to patients without ACEi/ARB use. We calculated pooled hazard ratios (HR) and their 95% confidence intervals (CI) using a random-effects model.

RESULTS

Twenty-five studies were included in the meta-analysis. Continued use of ACEi/ARBs in hospitalized patients with HFrEF was associated with lower 1-year mortality risk (pooled HR 0.68 [0.60-0.77] p < 0.001) and with lower 1-6-year mortality risk in those with heart failure preserved ejection fraction (HFpEF) (pooled HR 0.86 [0.78-0.94] p = 0.002). There were significant reductions in 1-year HF readmissions among hospitalized HFrEF patients (pooled HR 0.83 [0.73-0.95] p = 0.005).

CONCLUSION

Maintaining or initiating patients with HFrEF hospitalized for acute decompensated heart failure (ADHF) on ACEi/ARB is associated with a reduce risk of mortality and 1-year admissions, but the effect size is lower among those with HFpEF with more heterogeneous outcomes.

RAAS: A Convergent Player in Ischemic Heart Failure and Cancer

The current global prevalence of heart failure is estimated at 64.34 million cases, and it is expected to increase in the coming years, especially in countries with a medium-low sociodemographic index where the prevalence of risk factors is increasing alarmingly. Heart failure is associated with many comorbidities and among them, cancer has stood out as a contributor of death in these patients. This connection points out new challenges both in the context of the pathophysiological mechanisms involved, as well as in the quality of life of affected individuals. A hallmark of heart failure is chronic activation of the renin-angiotensin-aldosterone system, especially marked by a systemic increase in levels of angiotensin-II, a peptide with pleiotropic activities. Drugs that target the renin-angiotensin-aldosterone system have shown promising results both in the prevention of secondary cardiovascular events in myocardial infarction and heart failure, including a lower risk of certain cancers in these patients, as well as in current cancer therapies; therefore, understanding the mechanisms involved in this complex relationship will provide tools for a better diagnosis and treatment and to improve the prognosis and quality of life of people suffering from these two deadly diseases.

Beta-Blocker and Renin-Angiotensin System Inhibitor Combination Therapy in Patients with Acute Myocardial Infarction and Prediabetes or Diabetes Who Underwent Successful Implantation of Newer-Generation Drug-Eluting Stents: A Retrospective Observational Registry Study

Long-term clinical outcomes in patients with acute myocardial infarction (AMI) and prediabetes or diabetes who received ß-blockers (BB) and renin–angiotensin system inhibitor (RASI) therapy after successful newer-generation drug-eluting stent (DES) implantation are limited. We compared the two-year clinical outcomes in such patients. A total of 9466 patients with AMI in the Korea AMI Registry were classified into six groups according to their glycemic status and presence or absence of BB + RASI therapy: normoglycemia and BB + RASI users (n = 2217) or nonusers (n = 243), prediabetes and BB + RASI users (n = 2601) or nonusers (n = 306), and diabetes and BB + RASI users (n = 3682) or nonusers (n = 417). The primary endpoint was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction (Re-MI), or any repeat revascularization, and the secondary endpoint was the cumulative incidence of hospitalization for heart failure (HHF). In patients with BB + RASI, despite similar primary and secondary clinical points between the prediabetes and diabetes groups, the cumulative incidence of Re-MI (adjusted hazard ratio: 1.660; 95% confidence interval: 1.000–2.755; p = 0.020) was higher in the diabetes group than in the prediabetes group. In all three different glycemic groups, BB + RASI users showed reduced MACEs, cardiac death, and HHF compared to those of BB + RASI nonusers. In this retrospective observational registry study, BB + RASI therapy showed comparable clinical outcomes except for Re-MI between prediabetes and diabetes in patients with AMI during a two-year follow-up period.

Beta-blockers and renin-angiotensin system inhibitors in acute myocardial infarction managed with inhospital coronary revascularization

Pivotal trials of beta-blockers (BB) and angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) in acute myocardial infarction (AMI) were largely conducted prior to the widespread adoption of early revascularization. A total of 15,073 patients with AMI who underwent inhospital coronary revascularization from January 2007 to December 2013 were analyzed. At 12 months, BB was significantly associated with a lower incidence of major adverse cardiovascular events (MACE, adjusted HR 0.80, 95% CI 0.70–0.93) and all-cause mortality (adjusted HR 0.69, 95% CI 0.55–0.88), while ACEI/ARB was significantly associated with lower all-cause mortality (adjusted HR 0.80, 95% CI 0.66–0.98) and heart failure (HF) hospitalization (adjusted HR 0.80, 95% CI 0.68–0.95). Combined BB and ACEI/ARB use was associated with the lowest incidence of MACE (adjusted HR 0.70, 95% CI 0.57–0.86), all-cause mortality (adjusted HR 0.55, 95% CI 0.40–0.77) and HF hospitalization (adjusted HR 0.64, 95% CI 0.48–0.86). This were consistent for left ventricular ejection fraction < 50% or ≥ 50%. In conclusion, in AMI managed with revascularization, both BB and ACEI/ARB were associated with a lower incidence of 12-month all-cause mortality. Combined BB and ACEI/ARB was associated with the lowest incidence of all-cause mortality and HF hospitalization.