Key result
ARB use in acute MI is linked to ~13% lower 1-year mortality versus ACEI.
Why the study?
Due to superior ARB tolerance, the comparative efficacy of ACEI and ARB in acute MI, particularly in East Asian populations, remains controversial.
Does ARB reduce 1-year all-cause mortality compared to ACEI in patients with acute myocardial infarction?
Does ARB reduce 1-year all-cause mortality compared to ACEI in patients with acute myocardial infarction?
In a real-world East Asian cohort of acute MI patients, ARB use was associated with significantly lower 1-year all-cause and cardiovascular mortality compared to ACEI.
Does not support switching to ARB-first in acute MI; challenges ACEI consensus but remains hypothesis-generating pending RCTs.
Background Angiotensin-converting enzyme inhibitors (ACEI) are recommended as the first-line treatment in acute myocardial infarction (MI) guidelines, with angiotensin II receptor blockers (ARB) as the second choice. Due to the superior tolerance of ARB, the comparison of efficacy between ACEI and ARB, particularly in East Asian populations, remains controversial. Purpose To compare the effectiveness of ACEI and ARB in acute MI patients using real-world data from China. Methods This cohort study utilized a target trial emulation approach, including acute MI patients from province-wide electronic health records in China between 2013 and 2022. Patients with ACEI/ARB prescriptions within 180 days before the index date were excluded. Eligible patients with ACEI or ARB prescriptions during hospitalization were matched 1:1 using propensity scores and tracked for 1 year or until death (intention-to-treat analysis). Nonadherent patients were censored in the per-protocol analysis. The primary outcome was 1-year all-cause mortality, with secondary outcomes including cardiovascular mortality, recurrent MI, and stroke. Results In a matched cohort of 38,570 patients (19,285 per group), 2,553 (6.62%) deaths occurred, with 1,358 (7.04%) in the ACEI group and 1,195 (6.20%) in the ARB group. ARB was associated with lower all-cause mortality (hazard ratio [HR]: 0.87, 95% confidence interval [CI]: 0.81–0.94) and cardiovascular mortality (HR: 0.85, 95% CI: 0.77–0.94) compared to ACEI, consistent in the per-protocol analysis. No significant differences were observed for recurrent MI (HR: 1.01, 95% CI: 0.93-1.10) or stroke (HR: 1.08, 95% CI: 0.98-1.19). Subgroup analysis showed that ARBs were associated with significantly reduced mortality risk in non-ST-segment elevation MI patients (HR: 0.79, 95% CI: 0.71-0.86). Sensitivity analyses confirmed these findings, and positive (HR for cough: 0.76, 95% CI:0.66-0.86) and negative (HR for pneumonia: 1.08, 95% CI: 0.99-1.18) control outcomes validated the robustness of the results. Conclusions In acute MI patients, ARB use was associated with reduced 1-year mortality compared to ACEI, highlighting the potential advantage of ARBs in East Asian populations. This study provides evidence to guide renin-angiotensin system inhibitor treatment choices in clinical practice.
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Li et al. (2025) studied this question. ARB use in acute MI patients was associated with a 13% lower 1-year all-cause mortality (HR 0.87) and 15% lower cardiovascular mortality (HR 0.85) vs ACEI.
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