Prognosis after discontinuing renin angiotensin aldosterone system inhibitor for heart failure with restored ejection fraction after acute myocardial infarction

Seung Hun Lee; Tae‐Min Rhee; Doosup Shin; David Hong; Ki Hong Choi; Hyun Kuk Kim; Taek Kyu Park; Jeong Hoon Yang; Young Bin Song; Joo‐Yong Hahn; Seung‐Hyuck Choi; Shung Chull Chae; Myeong‐Chan Cho; Chong Jin Kim; Ju Han Kim; Hyo‐Soo Kim; Hyeon‐Cheol Gwon; Myung Ho Jeong; Seung Hun Lee; Tae‐Min Rhee; David Hong; Ki Hong Choi; Hyun Kuk Kim; Taek Kyu Park; Young Bin Song; Joo‐Yong Hahn; Seung‐Hyuck Choi; Myeong‐Chan Cho; Chong Jin Kim; Hyo‐Soo Kim; Hyeon‐Cheol Gwon

doi:10.1038/s41598-023-30700-1

Why the study?

The prognostic effect of discontinuing RAASi in post-AMI HF patients whose LV systolic function was restored during follow-up is unknown.

Does discontinuing RAASi increase the risk of all-cause death, spontaneous MI, or rehospitalization for HF in post-AMI HF patients with restored LVEF?

Structured PICO

Does discontinuing RAASi increase the risk of all-cause death, spontaneous MI, or rehospitalization for HF in post-AMI HF patients with restored LVEF?

P

Population

726 post-AMI HF patients with restored LVEF (baseline LVEF < 50% restored to ≥ 50% at 12-month follow-up) from the nationwide, multicenter, prospective Korea Acute Myocardial Infarction-National Institutes of Health (KAMIR-NIH) registry.

I

Intervention

Discontinuing renin-angiotensin-aldosterone-system-inhibitor (RAASi) beyond 12 months (Stop-RAASi, n=108).

C

Comparator

Maintaining RAASi beyond 12 months (Maintain-RAASi, n=544) or not using RAASi at baseline and follow-up (RAASi-Not-Used, n=74).

O

Outcome

Composite of all-cause death, spontaneous MI, or rehospitalization for HF at 36-month after index procedure.composite

Discontinuing RAASi in post-AMI heart failure patients with restored LVEF is associated with a more than twofold increased risk of adverse cardiovascular events compared to maintaining therapy.

Implication

May warrant caution against RAASi discontinuation in restored-EF post-AMI HF; leaves open need for randomized trials to confirm observational associations.

Abstract

Prognostic effect of discontinuing renin–angiotensin–aldosterone-system-inhibitor (RAASi) for patients with heart failure (HF) after acute myocardial infarction (AMI) whose left ventricular (LV) systolic function was restored during follow-up is unknown. To investigate the outcome after discontinuing RAASi in post-AMI HF patients with restored LV ejection fraction (EF). Of 13,104 consecutive patients from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction-National Institutes of Health (KAMIR-NIH) registry, HF patients with baseline LVEF < 50% that was restored to ≥ 50% at 12-month follow-up were selected. Primary outcome was a composite of all-cause death, spontaneous MI, or rehospitalization for HF at 36-month after index procedure. Of 726 post-AMI HF patients with restored LVEF, 544 maintained RAASi (Maintain-RAASi) beyond 12-month, 108 stopped RAASi (Stop-RAASi), and 74 did not use RAASi (RAASi-Not-Used) at baseline and follow-up. Systemic hemodynamics and cardiac workloads were similar among groups at baseline and during follow-up. Stop-RAASi group showed elevated NT-proBNP than Maintain-RAASi group at 36-month. Stop-RAASi group showed significantly higher risk of primary outcome than Maintain-RAASi group (11.4% vs. 5.4%; adjusted hazard ratio [HRadjust] 2.20, 95% confidence interval [CI] 1.09–4.46, P = 0.028), mainly driven by increased risk of all-cause death. The rate of primary outcome was similar between Stop-RAASi and RAASi-Not-Used group (11.4% vs. 12.1%; HRadjust 1.18 [0.47–2.99], P = 0.725). In post-AMI HF patients with restored LV systolic function, RAASi discontinuation was associated with significantly increased risk of all-cause death, MI, or rehospitalization for HF. Maintaining RAASi will be necessary for post-AMI HF patients, even after LVEF is restored.