Comparison of clinical outcomes between ACE inhibitor and ARB in AMI patients with dyslipidemia after successful stent implantation

Q: What are the key findings of this study?

Angiotensin receptor blockers were associated with a similar risk of major adverse cardiac events (aHR 1.305) but a significantly higher risk of all-cause death (aHR 2.277) compared to ACE inhibitors in patients with acute myocardial infarction and dyslipidemia.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Acute myocardial infarction (AMI) with dyslipidemia (n=3015). Intervention: Angiotensin II type 1 receptor blockers (ARBs) vs. Angiotensin-converting-enzyme inhibitors (ACEIs). Primary outcome: Major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization (aHR 1.305, 95% CI 0.911-1.869, p=0.146).

Q: What does this research mean for the field?

ACE inhibitors are associated with a lower risk of all-cause death compared to ARBs, despite similar rates of major adverse cardiac events, in patients with acute myocardial infarction and dyslipidemia following successful stent implantation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Yong Hoon Kim

doi:10.14744/anatoljcardiol.2019.60374

January 1, 2019The Anatolian Journal of CardiologyOpen Access

Comparison of clinical outcomes between ACE inhibitor and ARB in AMI patients with dyslipidemia after successful stent implantation

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Key result

ARBs linked to similar MACE but ~128% higher all-cause mortality versus ACE inhibitors after AMI.

Why the study?

Comparative data regarding long-term major clinical outcomes between ACEIs and ARBs in patients with AMI and dyslipidemia after successful stent implantation are limited.

Does ACE inhibitor therapy compared to ARB therapy improve clinical outcomes in AMI patients with dyslipidemia after successful stent implantation?

Key Points

To compare 2-year major clinical outcomes between ACE inhibitor and ARB therapy in patients with acute myocardial infarction and dyslipidemia following successful stent implantation.
Retrospective multicenter cohort study analyzing 3015 AMI patients with dyslipidemia from the Korea AMI Registry (KAMIR) who underwent successful stenting and received ACEIs (n=2175) or ARBs (n=840).
Follow-up was conducted for 2 years tracking major adverse cardiac events (MACEs), defined as all-cause death, recurrent MI, and any repeat revascularization (TLR, TVR, non-TVR).
Multivariable Cox proportional hazards regression was performed adjusting for demographic, clinical, angiographic, and medication covariates.
The cumulative incidence of all-cause death was significantly higher in the ARB group compared with the ACEI group (aHR, 2.277; 95% CI, 1.154-4.495; p=0.018).
Incidences of MACEs (aHR, 1.305; 95% CI, 0.911-1.869; p=0.146), cardiac death, recurrent MI, and repeat revascularization were similar between the groups.
Independent predictors of all-cause death included age ≥65 years, left ventricular ejection fraction <50%, and cardiopulmonary resuscitation on admission.

Study Design

Type

Observational (n=3,015)

Multicenter

Yes

Structured PICO

Does ACE inhibitor therapy compared to ARB therapy improve clinical outcomes in AMI patients with dyslipidemia after successful stent implantation?

P

Population

3,015 patients with acute myocardial infarction and dyslipidemia who underwent successful stent implantation, followed for 2 years to compare the clinical outcomes of ACE inhibitors versus ARBs.

E

Exposure

Angiotensin-converting-enzyme inhibitors (ACEIs) prescribed at discharge

C

Comparator

Angiotensin II type 1 receptor blockers (ARBs) prescribed at discharge

O

Outcome

Major adverse cardiac events (MACEs) defined as a composite of all-cause death, recurrent myocardial infarction (Re-MI), and any repeat-revascularization (target lesion revascularization [TLR], target vessel revascularization [TVR], and non-TVR) at 2 yearscomposite

Main Result

Hazard Ratio: 1.305 (95% CI 0.911–1.869)

p-value: p=0.146

In patients with AMI and dyslipidemia undergoing successful stent implantation, ACE inhibitors were associated with a lower risk of all-cause death at 2 years compared to ARBs.

Limitations

Missing data on causes of non-cardiac death due to registry limitations
Lack of data on medication dose changes, long-term compliance, crossover, and adverse events during follow-up
Dyslipidemia definition based on Asian guidelines may not generalize to other races or regions
Missing information on criteria and health status at the initiation of ACEI/ARB therapy
Lack of follow-up lipid profile data to assess target LDL achievement
Potential residual confounding despite multivariable adjustment
Under-reported or missing data due to registry limitations (e.g., causes of non-cardiac death)
Based on medications at discharge without data on dose changes, compliance, or crossover during follow-up
Dyslipidemia defined by Asian guidelines which may differ by race and region
Lack of information concerning the criteria for initiation of ACEIs and ARBs
Lack of follow-up lipid profiles to assess achievement of target blood cholesterol levels
Potential unmeasured confounders despite multiple Cox proportional hazard regression analysis

Implication

May favor ACE inhibitors over ARBs to reduce mortality after AMI with dyslipidemia; observational data leaves open need for randomized confirmation.

Abstract

OBJECTIVE: Currently, there are limited comparative data concerning long-term major clinical outcomes following the angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin II type 1 (AT1) receptor blockers (ARBs) therapy in patients with acute myocardial infarction (AMI) with dyslipidemia after a successful stent implantation. Therefore, we investigated major clinical outcomes for 2 years following the ACEIs and ARBs therapy in these patients. METHODS: A total of 3015 patients with AMI who underwent a successful stent implantation and were prescribed ACEIs (n=2175) or ARBs (n=840) were enrolled into the study from the Korea AMI Registry (KAMIR). The major clinical endpoint was the occurrence of major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat-revascularization-comprised target lesion revascularization (TLR), target vessel revascularization (TVR), and non-TVR. RESULTS: After the adjustment, the cumulative incidence of all-cause death in the ARBs group was significantly higher than in the ACEIs group [adjusted hazard ratio (aHR), 2.277; 95% confidence interval (CI), 1.154-4.495; p=0.018]. The cumulative incidences of MACEs (aHR, 1.305; 95% CI, 0.911-1.869; p=0.146), cardiac death, Re-MI, any repeat revascularization, TLR, TVR, and non-TVR were similar between the two groups. In addition, an advanced age (≥65 years), decreased left ventricular ejection fraction (<50%), and cardiopulmonary resuscitation on admission were meaningful independent predictors for all-cause death in this study. CONCLUSION: ACEIs were a preferred treatment modality when compared to ARBs for patients with AMI with dyslipidemia who underwent a successful stent implantation to reduce the incidences of all-cause death during a 2-year follow-up. However, additional research is required to determine the clinical implications of these results.

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Published by The Anatolian Journal of Cardiology · CC BY-NC-SA

Cite This Study

Yong Hoon Kim (2019) conducted an observational in Acute myocardial infarction (AMI) with dyslipidemia (n=3,015). Angiotensin II type 1 receptor blockers (ARBs) vs. Angiotensin-converting-enzyme inhibitors (ACEIs) was evaluated on Major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization (aHR 1.305, 95% CI 0.911-1.869, p=0.146). Angiotensin receptor blockers were associated with a similar risk of major adverse cardiac events (aHR 1.305) but a significantly higher risk of all-cause death (aHR 2.277) compared to ACE inhibitors in patients with acute myocardial infarction and dyslipidemia.

synapsesocial.com/papers/6a1c22d1ea84844e355f80b2 https://doi.org/10.14744/anatoljcardiol.2019.60374

Topics

Lipid management

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Comparison of clinical outcomes between ACE inhibitor and ARB in AMI patients with dyslipidemia after successful stent implantation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Figures from the paper

Cite This Study

Topics

Comparison of clinical outcomes between ACE inhibitor and ARB in AMI patients with dyslipidemia after successful stent implantation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Figures from the paper

Cite This Study

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