Angiotensin II receptor blockers versus angiotensin-converting enzyme inhibitors in patients with stable coronary artery disease: Prevalence, correlates, and prognostic impact (from the CORONOR study)

Angiotensin-Converting Enzyme Inhibitor-based Versus Angiotensin Receptor Blocker-based Optimal Medical Therapy After Percutaneous Coronary Intervention: A Nationwide Cohort Study

ABSTRACT

Optimal medical therapy (OMT) plays a crucial role in the secondary prevention of established coronary artery disease. The renin-angiotensin system (RAS) is an important target of OMT. However, there is limited evidence on whether there is any difference in the combined effect of OMT according to the classes of RAS blockade [angiotensin-converting enzyme inhibitor (ACEI) vs. angiotensin receptor blocker (ARB)]. Based on the nationwide National Health Insurance database in South Korea, 39,096 patients who received OMT after percutaneous coronary intervention between July 2013 and June 2017 were enrolled. Patients were stratified into either acute myocardial infarction (AMI) or angina cohort and analyzed according to the class of RAS blockade included in OMT at discharge (ACEI vs. ARB). The primary end point was all-cause mortality. The study population had a median follow-up of 2.3 years (interquartile range, 1.3-3.3 years). In the propensity score-matched AMI cohort (8219 pairs), the risk for all-cause mortality was significantly lower in patients with ACEI-based OMT than in those with ARB-based OMT (hazard ratio 0.83 of ACEI, 95% confidence interval 0.73-0.94, P = 0.003). However, in the propensity score-matched angina cohort (6693 pairs), the mortality risk was comparable, regardless of the class of RAS blockade (hazard ratio 1.13, 95 confidence interval 0.99-1.29, P = 0.08). In conclusion, in this nationwide cohort study involving patients receiving OMT after percutaneous coronary intervention, ACEI-based OMT was associated with a significantly lower risk of all-cause mortality in patients with AMI in comparison with ARB, but not in those with angina.

A Study of Morphological Changes in Renal Afferent Arterioles Induced by Angiotensin II Type 1 Receptor Blockers in Hypertensive Patients

BACKGROUND

Renin-angiotensin-aldosterone system blockers are known to reduce hypertrophy of vascular smooth muscle cells (SMCs) in hypertensive cases. However, we have reported marked proliferative changes of renal afferent arteriolar SMCs in rats induced by a long-term administration of angiotensin II type 1 receptor blockers (ARBs) and an angiotensin-converting enzyme inhibitor (ACEI). In this study, we examined the morphological changes of afferent arteriolar walls in human kidneys with or without ARBs/ACEIs.

METHODS

Forty-four wedge resections were taken from patients aged 45-74 years from 92 nephrectomized kidneys due to malignancy at Toho University Omori Medical Center between 2013 and 2016. They were divided into the following three groups: 18 hypertensive patients treated with antihypertensive agents including ARBs or ACEIs (the HTARB group), 6 hypertensive patients treated with calcium channel blockers without ARBs/ACEIs (the HTCCB group), and 20 normotensive patients (the normotensive group) as a control. Cases expecting vascular changes such as diabetes were excluded. In each case renal arterioles were measured as the ratio of inner/outer arteriolar diameter, and pathologists estimated morphological abnormal changes, scoring each specimen independently.

RESULTS

The ratio in the HTARB group was 0.39 ± 0.05 (mean ± SD), and was significantly the lowest among the three groups (0.46 ± 0.02 in the HTCCB, 0.53 ± 0.02 in the normotensive group; p = 0.0107 vs. HTCCB, p = 0.00001 vs. normotensive). The ratio in the three groups significantly correlated with the estimated glomerular filtration rate (r = 0.4915, p < 0.0007). The afferent arteriolar SMCs in the HTARB group frequently showed marked proliferative and irregular changes. The score of SMC abnormalities estimated regarding the proliferation, irregularity of the arrangement, and size in hilar afferent arteriolar SMCs was highest in the HTARB group and showed statistical significance (p = 0.0088, p = 0.00001, and p = 0.025 versus other two groups).

CONCLUSIONS

We consider that these morphological changes in arterioles are induced by ARBs/ACEIs. These changes could induce an important suppression of glomerular hyperfiltration and could lead to glomerular ischemia. However, the clinical consequences of these morphological changes in correlation with ARBs/ACEIs were not sufficiently clear and require further analysis. We should consider renal arteriolar morphological changes when using ARBs/ACEIs.

Evidence in Guidelines for Treatment of Coronary Artery Disease

In this chapter, we focus on evidences in current guidelines for treatment of coronary artery disease (CAD). In Part 1, diet and lifestyle management is discussed, which plays an important role in CAD risk control, including forming healthy dietary pattern, maintaining proper body weight, physical exercise, smoking cessation, and so on. Part 2 elaborated on revascularization strategies and medical treatments in patients presenting with acute coronary syndrome (ACS), including specific AHA and ESC guidelines on ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). Part 3 discussed chronic stable coronary artery disease (SCAD), the treatment objective of which is a combination of both symptomatic and prognostic improvement. Yet many of the recommendations for SCAD are expert-based rather than evidence-based. Initial medical treatment is safe and beneficial for most patients. While cumulating studies have focused on optimizing pharmacological therapy (referring to nitrates, beta-blockers, calcium channel blockers, antiplatelet agents, ACEI/ARB, statins, etc.), education, habitual modification, and social support matters a lot for reducing cardiac morbidity and mortality. Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization. But practical management of revascularization shall take individual characteristics, preference, and compliance into consideration as well.

Angiotensin Receptor Blockers as an Alternative to Angiotensin-Converting Enzyme Inhibitors in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEIs) are the first choice for the treatment of acute myocardial infarction (AMI), and angiotensin receptor blockers (ARBs) should be considered in patients intolerant to ACEIs. Although previous studies support the use of ARBs as an alternative to ACEIs, these studies showed inconsistent results. The objective of this study was to demonstrate the clinical impact of ARBs as an alternative to ACEIs in patients with AMI undergoing percutaneous coronary intervention (PCI).

METHODS

The CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI (COREA-AMI) registry enrolled all consecutive patients with AMI undergoing PCI. The primary endpoint was the composite of cardiovascular death, myocardial infarction, stroke, or hospitalization due to heart failure.

RESULTS

Of the 3,328 eligible patients, ARBs replaced ACEIs in 816 patients, while 824 patients continued to use ACEIs and 826 patients continued to use ARBs. The remaining 862 patients did not receive ACEIs/ARBs. After the adjustment with inverse probability weighting, the primary endpoints in the first groups were similar (7.5% vs. 8.0%, hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.75-1.05; P = 0.164). Composite events were less frequent in the ACEI to ARB group than no ACEI/ARB group (7.5% vs. 11.8%, HR, 0.76; 95% CI, 0.64-0.90; P = 0.002).

CONCLUSION

The alternative use of ARBs following initial treatment with ACEIs demonstrates comparable clinical outcomes to those with continued use of ACEIs and is associated with an improved rate of composite events compared to no ACEI/ARB use in patients with AMI undergoing PCI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02385682.