Comparative effectiveness of ACE inhibitors and angiotensin receptor blockers in patients with prior myocardial infarction

Prolonged pain-to-balloon time still impairs midterm left ventricular function following STEMI

BACKGROUND

ST-elevation myocardial infarction (STEMI) demands near-time reperfusion to reduce the risk of long-term heart failure. This study evaluates the proportion of impaired left ventricular ejection fraction (LVEF) following STEMI in the context of current healthcare settings at a tertiary care center equipped with the most advanced and up-to-date standards of care.

METHODS

Patients experiencing STEMI as their first manifestation of coronary artery disease were analyzed, as these individuals had no prior experience with heart-related chest pain. LVEF was assessed by levocardiography at admission and semiautomatically using TOMTEC in patients with eligible full-cycle echocardiography of 2- and 4-chamber view available at discharge and 1-year follow-up (FU). Pain-to-balloon time was divided into quartiles (Q) [0-111, 112-159, 160-246 and 247-784 min]. Multiple logistic regression analysis identified independent predictors of reduced LVEF < 50% at 1-year FU.

RESULTS

A total of 1,379 consecutive STEMI patients were reviewed from 2010 to 2017, with 130 meeting the inclusion criteria. Mean age was 63 ± 12 years, 75% were male, 14% had diabetes, 72% had arterial hypertension, and 56% had history of smoking. LVEF was reduced in 94% of patients at admission, 69% at discharge, and remained reduced in 45% at the 1-year follow-up. Anterior wall myocardial infarction (OR 3.2 [95%-CI 1.2-6.9], p = 0.018) and increasing pain-to-balloon time across quartiles (Q2: OR 15.7 [95%-CI 1.8-140.4], p = 0.014; Q4: OR 33.7 [3.4-278.7] p = 0.002) were independently associated with reduced LVEF at 1 year.

CONCLUSION

Despite optimal medical management and advanced healthcare structures, nearly half of patients with STEMI as their first presentation of coronary artery disease continue to exhibit reduced LVEF at 12-months. Anterior wall myocardial infarction and pain-to-balloon time exceeding 2 h remain independent predictors of left ventricular dysfunction. Further improvements in healthcare systems and public education are essential to reduce treatment delays and improve long-term outcomes.

Comparison of Outcomes Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Patients With Myocardial Infarction: A Meta-Analysis

Patients with acute myocardial infarction (AMI) are usually treated with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB). The aim of this meta-analysis is to compare outcomes between ACEi and ARB in patients with myocardial infarction (MI). This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Three major online databases, including PubMed, EMBASE, and the Cochrane Library, were thoroughly searched to find studies comparing ACEi and ARB in patients with MI from January 1, 2000, onwards, without language or publication restrictions. Outcomes assessed in this meta-analysis included major adverse cardiovascular events (MACE), all-cause mortality, cardiovascular mortality, stroke, and hospitalization due to heart failure. A total of 16 studies were included in this meta-analysis. Pooled estimates showed no significant differences between the two groups in terms of MACE (risk ratio (RR): 1.03, 95% confidence interval (CI): 0.88-1.20), all-cause mortality (RR: 1.03, 95% CI: 0.88-1.20), cardiovascular mortality (RR: 1.00, 95% CI: 0.89-1.12), stroke (RR: 1.03, 95% CI: 0.80-1.32), and hospitalization due to heart failure (RR: 0.99, 95% CI: 0.90-1.09). These results suggest that ACEi and ARB have similar impacts on clinical outcomes across a broad spectrum of MI patients, reinforcing their roles in post-MI treatment.

Heart Failure in Patients with Chronic Kidney Disease

The function of the kidney is tightly linked to the function of the heart. Dysfunction/disease of the kidney may initiate, accentuate, or precipitate of the cardiac dysfunction/disease and vice versa, contributing to a negative spiral. Further, the reciprocal association between the heart and the kidney may occur on top of other entities, usually diabetes, hypertension, and atherosclerosis, simultaneously affecting the two organs. Chronic kidney disease (CKD) can influence cardiac function through altered hemodynamics and salt and water retention, leading to venous congestion and therefore, not surprisingly, to heart failure (HF). Management of HF in CKD is challenging due to several factors, including complex interplays between these two conditions, the effect of kidney dysfunction on the metabolism of HF medications, the effect of HF medications on kidney function, and the high risk for anemia and hyperkalemia. As a result, in most HF trials, patients with severe renal impairment (i.e., eGFR 30 mL/min/1.73 m2 or less) are excluded. The present review discusses the epidemiology, pathophysiology, and current medical management in patients with HF developing in the context of CKD.

Effect of Angiotensin Receptor Blocker Dose in Myocardial Infarction With Preserved Left Ventricular Systolic Function

ABSTRACT

There have been few studies of angiotensin receptor blocker (ARB) dose in myocardial infarction (MI) with preserved left ventricular (LV) systolic function. We evaluated the association of ARB dose with clinical outcomes after MI with preserved LV systolic function. We used MI multicenter registry. Six months after discharge, the ARB dose was indexed to the target ARB doses used in randomized clinical trials and grouped as >0%-25% (n = 2333), >25% of the target dose (n = 1204), and no ARB (n = 1263). The primary outcome was the composite of cardiac death or MI. Univariate analysis showed that mortality of those with any ARB dose was lower than those without ARB therapy. After multivariable adjustment, patients receiving >25% of target dose had a similar risk of cardiac death or MI compared with those receiving ≤25% or no ARB [hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.83-1.33; HR 0.94, 95% CI 0.82-1.08, respectively]. Propensity score analysis also demonstrated that patients with >25% dose had no difference in primary endpoint compared with those ≤25% dose or the no ARB group (HR 1.03, 95% CI 0.79-1.33; HR 0.86, 95% CI 0.64-1.14, respectively). The present study demonstrates that patients treated with >25% of target ARB dose do not have better clinical outcomes than those treated with ≤25% of target ARB dose or those with no ARB dose in MI patients with preserved LV systolic function.

Impact of angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers on clinical outcomes in hypertensive patients with acute myocardial infarction

There has been a concern that angiotensin receptor blockers (ARB) may increase myocardial infarction (MI) in hypertensive patients compared with other classes of anti-hypertensive drugs. Angiotensin-converting enzyme inhibitor (ACEI) is recommended as a first-line inhibitor of renin-angiotensin system (RASI) in patients with acute MI (AMI), but ARB is also frequently used to control blood pressure. This study investigated the association of ARB vs. ACEI with the long-term clinical outcomes in hypertensive patients with AMI. Among patients enrolled in the nationwide AMI database of South Korea, the KAMIR-NIH, 4,827 hypertensive patients, who survived the initial attack and were taking ARB or ACEI at discharge, were selected for this study. ARB therapy was associated with higher incidence of 2-year major adverse cardiac events, cardiac death, all-cause death, MI than ACEI therapy in entire cohort. After propensity score-matching, ARB therapy was still associated with higher incidence of 2-year cardiac death (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.20-2.14; P = 0.001), all-cause death (HR, 1.81; 95% CI, 1.44-2.28; P < 0.001), and MI (HR, 1.76; 95% CI, 1.25-2.46; P = 0.001) than the ACEI therapy. It was concluded that ARB therapy at discharge in hypertensive patients with AMI was inferior to ACEI therapy with regard to the incidence of CD, all-cause death, and MI at 2-year. These data suggested that ACEI be a more appropriate RASI than ARB to control BP in hypertensive patients with AMI.

Left Ventricular Remodeling after Myocardial Infarction: From Physiopathology to Treatment

Myocardial infarction (MI) is the leading cause of death and morbidity worldwide, with an incidence relatively high in developed countries and rapidly growing in developing countries. The most common cause of MI is the rupture of an atherosclerotic plaque with subsequent thrombotic occlusion in the coronary circulation. This causes cardiomyocyte death and myocardial necrosis, with subsequent inflammation and fibrosis. Current therapies aim to restore coronary flow by thrombus dissolution with pharmaceutical treatment and/or intravascular stent implantation and to counteract neurohormonal activation. Despite these therapies, the injury caused by myocardial ischemia leads to left ventricular remodeling; this process involves changes in cardiac geometry, dimension and function and eventually progression to heart failure (HF). This review describes the pathophysiological mechanism that leads to cardiac remodeling and the therapeutic strategies with a role in slowing the progression of remodeling and improving cardiac structure and function.

The Renin-Angiotensin-Aldosterone System in Postmenopausal Women: The Promise of Hormone Therapy

Estradiol (E2) plays an underrecognized role in modulating body-wide systems, including important interactions with the renin-angiotensin-aldosterone system (RAAS). The RAAS is an immunomodulating system that is critical for maintaining homeostasis across multiple organ systems. The diverse interactions between E2 and the RAAS help maintain cardiometabolic homeostasis, including successful physiologic responses to trauma and infectious pathogens. Estradiol deficiency (ie, menopause) results in impaired responses and increased susceptibility to infectious pathogens. Both immune and cardiometabolic function decline with reduced E2 production, in part because the RAAS becomes dysregulated by E2 deficiency, leaving RAAS predominantly in its proinflammatory state and predisposing to systemic low-grade inflammation. Estradiol deficiency and RAAS dysregulation contribute to impaired immune responses and increased incidence of cardiac hypertrophy, hypertension, atherosclerotic cardiovascular disease, arrhythmias, and heart failure. The RAAS consists of dual, counterbalancing pathways-proinflammatory and anti-inflammatory. Estradiol is a signaling agent that plays a major role in determining which RAAS pathway predominates. The proinflammatory pathway is activated early in response to infection or trauma, followed by up-regulation of the anti-inflammatory pathway, to resolve inflammation and to restore homeostasis. Estradiol influences activation of the "switch" to restore the anti-inflammatory state. The dysregulated RAAS is a primary target of current cardiovascular therapeutics focused on blocking portions of its proinflammatory pathway. However, RAAS-modifying pharmaceuticals often provide imperfect solutions to these physiologic disruptions and underscore the need for improved approaches to menopausal medicine. Estradiol therapy and optimal lifestyle practices combined with RAAS-modifying pharmaceuticals may be an ideal strategy to optimize postmenopausal health.

Renin-angiotensin-aldosterone system inhibitors and major cardiovascular events and acute kidney injury in patients with coronary artery disease

BACKGROUND

Renin-angiotensin-aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD.

METHODS

Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment-weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers).

RESULTS

There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse-probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93-0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02-1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82-0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97-1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66-1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19-1.57, interaction p < 0.01).

CONCLUSIONS

This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High-risk patients, particularly those with prior MI, appear to benefit the most from RAASIs.

Comparative Effectiveness of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors in Older Nursing Home Residents After Myocardial Infarction: A Retrospective Cohort Study

BACKGROUND

Evidence regarding differences in outcomes between angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) among older nursing home (NH) residents after acute myocardial infarction (AMI) is limited.

OBJECTIVES

The purpose of our study was to estimate the post-AMI effects of ARBs versus ACEIs on mortality, rehospitalization, and functional decline outcomes in this important population.

METHODS

This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population included individuals aged ≥ 65 years who resided in a US NH ≥ 30 days, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. We compared 90-day mortality, rehospitalization, and functional decline outcomes between ARB and ACEI users with inverse-probability-of-treatment-weighted binomial and multinomial logistic regression models.

RESULTS

Of the 2765 NH residents, 270 (9.8%) used ARBs and 2495 (90.2%) used ACEIs. The mean age of ARB versus ACEI users was 82.3 versus 82.7 years, respectively. No marked differences existed between ARB and ACEI users for mortality [odds ratio (OR) 1.18; 95% confidence interval (CI) 0.78-1.79], rehospitalization (OR 1.22; 95% CI 0.90-1.65), or functional decline (OR 1.23; 95% CI 0.88-1.74). In subgroup analyses, ARBs were associated with increased mortality and rehospitalization in individuals with moderate to severe cognitive impairment and with increased rehospitalization in those aged < 85 years.

CONCLUSIONS

Our findings align with prior data and suggest that clinicians can prescribe either ARBs or ACEIs post-AMI for secondary prevention in NH residents, although the subgroup findings merit further scrutiny and replication. Providers should consider factors such as patient preferences, class-specific adverse events, and costs when prescribing.

Sex and the kidneys: current understanding and research opportunities

Concerns regarding sex differences are increasingly pertinent in scientific and societal arenas. Although biological sex and socio-cultural gender are increasingly recognized as important modulators of renal function under physiological and pathophysiological conditions, gaps remain in our understanding of the mechanisms underlying sex differences in renal pathophysiology, disease development, progression and management. In this Perspectives article, we discuss specific opportunities for future research aimed at addressing these knowledge gaps. Such opportunities include the development of standardized core data elements and outcomes related to sex for use in clinical studies to establish a connection between sex hormones and renal disease development or progression, development of a knowledge portal to promote fundamental understanding of physiological differences between male and female kidneys in animal models and in humans, and the creation of new or the development of existing resources and datasets to make them more readily available for interrogation of sex differences. These ideas are intended to stimulate thought and interest among the renal research community as they consider sex as a biological variable in future research projects.