ACEi/ARB after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST STEMI registry

Background The impact of adherence to angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real-world patients is understudied. Purpose To identify predictors of lower compliance to ACEi/ARBs and estimate its impact on cardiovascular outcomes and mortality in the first year after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of bought tablets in pharmacies to the expected tablets at 1 year and on total follow-up length. A total of 6043 patients with STEMI from 2012 to 2017 were enrolled in the FAST-STEMI registry and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events and ischemic stroke. The optimal compliance cutoff was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated at univariate and multivariate analysis with logistic regression. Results A total of 4167 patients with ACEi/ARBs prescription at discharge were considered: mean age was 64 ± 12 years old, 77.3% were men, 18.4% had hypertension, 12% were diabetic, 3.8% had previous coronary artery disease (CAD), mean ejection fraction (EF) was 49.21%±8.9%. Mean ACEi/ARBs adherence was 84.4% (IQR 57.5-99.8): after univariate and multivariate analysis, predictors of lower compliance were age ³75 years old (OR 0.822, 95%CI 0.697-0.970) and known ischemic cardiopathy (OR 0.592, 95%CI 0.422-0.831), whereas preserved EF (OR 1.197, 95%CI 1.048-1.368), hypertension (OR 1.339, 95%CI 1.114-1.609) and beta-blockers prescription at discharge (OR 1.442, 95%CI 1.155-1.802) were predictors of good adherence. ACEi/ARBs compliance higher than 72.06% (identified at Youden’s analysis as best cut-off) was found both at univariate and multivariate analysis as a predictor of lower cardiovascular (0.3% vs 2.6%, HR 0.17, 95%CI 0.07-0.36, p<0.001) and all-cause mortality (1.5% vs 5.9%, HR 0.34, 95%CI 0.23-0.51, p<0.001). Finally, ACEi/ARBs optimal compliance at 1-year was associated to a reduction of myocardial infarctions (7.7% vs 10.4%, p=0.02), as well as minor bleedings (0.2% vs 0.7%, p=0.01), whilst did not impact on ischemic stroke nor major bleedings. Conclusions In our large real-world registry, good adherence to ACEi/ARBs therapy after acute myocardial infarction with ST-elevation was associated with a reduction in mortality (either cardiovascular and all-cause), myocardial infarctions and minor bleedings. Older age and previous coronary artery disease resulted as predictors of poor compliance to ACEi/ARBs therapy.