ACE Inhibitors Versus ARBs in Patients With NSTEMI With Preserved LV Systolic Function Who Underwent PCI With New Generation Drug-Eluting Stents

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.

Role of renin-angiotensin system antagonists on long-term mortality post-percutaneous coronary intervention in reduced and preserved ejection fraction

AIMS

The use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II-receptor blockers (ARBs) post-myocardial infarction (MI) is supported by evidence based on trials performed in the thrombolysis era. This was prior to primary percutaneous coronary intervention (PCI) being routine practice, and with little direct evidence for the use of these medications in patients with preserved left ventricular (LV) function. This study sought to determine whether there is an association between ACEi/ARB use after PCI for acute coronary syndrome (ACS) and long-term all-cause mortality, with a particular focus on patients with preserved LV function.

METHODS

This multicentre, observational study evaluated prospectively collected data of 21,388 patients (> 18 years old) that underwent PCI for NSTEMI and STEMI between 2005 and 2018, and were alive at 30 day follow-up.

RESULTS

In total, 83.8% of patients were using ACEi/ARBs. Kaplan-Meier analysis demonstrated ACEi/ARB use was associated with a significantly lower mortality in the entire cohort (15.0 vs. 22.7%; p < 0.001) with a mean follow-up of 5.58 years; and independently associated with 24% lower mortality by Cox proportional hazards modelling (HR 0.76, CI 0.67-0.85, p < 0.001). ACEi/ARB therapy was also associated with significantly lower mortality in patients with reduced or preserved LV function, with greater survival benefit with worse LV dysfunction.

CONCLUSION

ACEi/ARB therapy post-PCI is associated with significantly lower long-term mortality in patients with reduced and preserved LV function. These findings provide contemporary evidence for using these agents in the current era of routine primary PCI, including those with preserved EF.

The impact of angiotensin-converting-enzyme inhibitors versus angiotensin receptor blockers on 3-year clinical outcomes in patients with acute myocardial infarction without hypertension

This study aimed to investigate the impact of angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) on 3-year clinical outcomes in acute myocardial infarction (AMI) patients without a history of hypertension who underwent successful percutaneous coronary intervention (PCI) with drug-eluting stents (DES). A total of 13,104 AMI patients who were registered in the Korea AMI registry (KAMIR)-National Institutes of Health (NIH) were included in the study. The primary endpoint was 3-year major adverse cardiac events (MACE), which was defined as the composite of all-cause death, recurrent myocardial infarction (MI), and any repeat revascularization. To adjust baseline potential confounders, an inverse probability weighting (IPTW) analysis was performed. The patients were divided into two groups: the ACEI group, n = 4,053 patients and the ARB group, n = 4,107 patients. During the 3-year clinical follow-up, the cumulative incidences of MACE (hazard ratio [HR], 0.843; 95% confidence interval [CI], 0.740-0.960; p = 0.010), any repeat revascularization (HR, 0.856; 95% CI, 0.736-0.995; p = 0.044), stroke (HR, 0.613; 95% CI, 0.417-0.901; p = 0.013), and re-hospitalization due to heart failure (HF) (HR, 0.399; 95% CI, 0.294-0.541; p <0.001) in the ACEI group were significantly lower than in the ARB group. In Korean patients with AMI without a history of hypertension, the use of ACEI was significantly associated with reduced incidences of MACE, any repeat revascularization, stroke, and re-hospitalization due to HF than those with the use of ARB.

Angiotensin-Converting Enzyme Inhibitors Versus Angiotensin II Receptor Blockers in Acute Coronary Syndrome and Preserved Ventricular Ejection Fraction

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin II receptor blockers (ARB) showed comparable survival results in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, there is lack of evidence of the comparative effectiveness in preserved LVEF patients after an acute coronary syndrome (ACS). The aim of this study was to evaluate whether the selection between ACEi and ARB in preserved LVEF after an ACS confers a prognostic benefit, based on real life results. We analyzed a cohort of 3006 contemporary patients with LVEF ≥40% after an ACS. A propensity score matching and Cox regression analysis were performed to assess the association between treatment and events (death, acute myocardial infarction [AMI], HF, and combined event) for a mean follow-up of 3.6 ± 2.1 years. We found no significant differences between ACEi/ARB for all-cause mortality (hazard ratio [HR] for ARB: 0.95, 95% CI: 0.70-1.29), AMI (HR for ARB: 1.34, 95% CI: 0.95-1.89), HF (HR for ARB: 1.11, 95% CI: 0.85-1.45), or combined end point (death, AMI and HF: HR for ARB: 1.14, 95% CI: 0.92-1.40). In conclusion, there are no prognostic differences between the use of ACEi and ARB in patients with LVEF ≥40% after ACS. Further prospective studies are needed to confirm our results.