Key result
ACEi/ARB fails to reduce major events in post-MI patients with preserved EF.
Why the study?
Randomised trials assessing ACEis and ARBs in patients with myocardial infarction and preserved ejection fraction (≥50%) are lacking.
Does ACEi/ARB treatment reduce the composite of death, myocardial infarction, or heart failure in patients under 75 years with myocardial infarction and preserved left ventricular ejection fraction (≥50%)?
Observational (n=15,427)
Yes
Does ACEi/ARB treatment reduce the composite of death, myocardial infarction, or heart failure in patients under 75 years with myocardial infarction and preserved left ventricular ejection fraction (≥50%)?
Effect estimate: Risk difference -0.3% (95% CI -1.6 to 1.0)
Absolute Event Rate: 7.8% vs 8.1%
Target trial emulation using nationwide registry data suggests that routine ACEi/ARB treatment does not improve clinical outcomes in post-myocardial infarction patients with preserved left ventricular ejection fraction.
No benefit of ACEi/ARB seen in post-MI preserved EF; challenges guidelines but leaves open confirmation by randomized trials.
Background Angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are effective in the long-term treatment of individuals with myocardial infarction (MI) and reduced left ventricular ejection fraction. However, there is a lack of randomised trials assessing these agents in those with preserved ejection fraction (≥50%). One approach is to use observational data to emulate a hypothetical pragmatic trial ("target trial") that one would conduct. Methods We emulated a target trial of ACEis/ARBs versus no ACEis/ARBs in individuals under the age of 75 years with MI and left ventricular ejection fraction ≥50% between September 2010 and June 2021 for the prevention of a composite outcome (death, myocardial infarction, or heart failure) and its individual components. We used the Sweden-wide SWEDEHEART quality registry with linkage to other national registers, enabling complete coverage of hospital care and dispensed drugs. We estimated observational analogues of the intention-to-treat effect and the per-protocol effect with confounding adjustment via inverse probability weighting. Results The 10,697 individuals in the ACEi/ARB group were on average older (median 61 vs 60 years), more likely to be male (80.2% vs 75.3% male) and more likely to present with STEMI (45.4% vs 27.9%) compared with the 4,730 individuals in the no ACEi/ARB group. In an intention-to-treat analysis, the estimated five-year risk of the composite outcome was 7.8% (95% confidence interval 7.1%, 8.5%) in the ACEi/ARB group and 8.1% (7.0%, 9.3%) in the non-ACEi/ARB group; risk difference -0.3% (-1.6%, 1.0%) (Figure 1). In a per protocol analysis, the risk of the composite outcome was 6.5% (5.9%, 7.2%) in the ACEi/ARB group and 6.7% (5.6%, 8.1%) in the no ACEi/ARB group; risk difference -0.2% (-1.7%, 1.0%) (Figure 2). Conclusions The estimated risk of a composite of death, myocardial infarction or heart failure was similar in recipients and non-recipients of ACEi/ARB. Our estimates suggest that ACEi/ARB treatment in patients with myocardial infarction and preserved left ventricular ejection fraction does not confer a benefit.Table and forest plot of ITT effect Table forest plot of perprotocol effect
No takes yet. Share an insight, caveat, or question.
Humphreys et al. (2025) conducted an observational in Myocardial infarction with preserved left ventricular ejection fraction (n=15,427). ACEi/ARB vs. No ACEi/ARB was evaluated on Composite outcome (death, myocardial infarction, or heart failure) (Risk difference -0.3%, 95% CI -1.6 to 1.0). In patients with MI and preserved ejection fraction, ACEi/ARB treatment did not reduce the 5-year risk of death, MI, or heart failure (risk difference -0.3%; 95% CI -1.6% to 1.0%).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: