Role of renin–angiotensin system antagonists on long-term mortality post-percutaneous coronary intervention in reduced and preserved ejection fraction

Hamish C Prosser,Melanie Freeman,Ernesto Oqueli,Andrew E Ajani,Angela Brennan,Diem Dinh,Jithin K Sajeev,Stephen J Duffy,Christopher M Reid,Martin Sebastian,Andrew W Teh,Kah Yong Peck,Jaya Chandrasekhar,David Clark,Louise Roberts

doi:10.1007/s00392-021-01985-x

Abstract

AimsThe use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II-receptor blockers (ARBs) post-myocardial infarction (MI) is supported by evidence based on trials performed in the thrombolysis era. This was prior to primary percutaneous coronary intervention (PCI) being routine practice, and with little direct evidence for the use of these medications in patients with preserved left ventricular (LV) function. This study sought to determine whether there is an association between ACEi/ARB use after PCI for acute coronary syndrome (ACS) and long-term all-cause mortality, with a particular focus on patients with preserved LV function.MethodsThis multicentre, observational study evaluated prospectively collected data of 21,388 patients (> 18 years old) that underwent PCI for NSTEMI and STEMI between 2005 and 2018, and were alive at 30 day follow-up.ResultsIn total, 83.8% of patients were using ACEi/ARBs. Kaplan–Meier analysis demonstrated ACEi/ARB use was associated with a significantly lower mortality in the entire cohort (15.0 vs. 22.7%; p < 0.001) with a mean follow-up of 5.58 years; and independently associated with 24% lower mortality by Cox proportional hazards modelling (HR 0.76, CI 0.67–0.85, p < 0.001). ACEi/ARB therapy was also associated with significantly lower mortality in patients with reduced or preserved LV function, with greater survival benefit with worse LV dysfunction.ConclusionACEi/ARB therapy post-PCI is associated with significantly lower long-term mortality in patients with reduced and preserved LV function. These findings provide contemporary evidence for using these agents in the current era of routine primary PCI, including those with preserved EF.Graphical abstract

Highlights

Optimal medical therapy plays a critical role in preventing further cardiovascular events and improving clinical outcomes following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) [1,2,3]
At 30 days, 17,926 patients (83.8%) were taking an Angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs), while 3462 (16.2%) were not (Table 1). Those who were on ACEi/ARB therapy at 30 days were younger, hypertensive, with elevated BMI, and a family history of CAD
Few patient characteristics differed between treatment groups in the smaller cohort of patients with ejection fraction (EF) < 35% (N = 1076), significantly fewer were on ACEi/ARB if hypertensive or a current smoker, and a greater proportion were on ACEi/ARB in the setting of prior PCI

Summary

Introduction

Optimal medical therapy plays a critical role in preventing further cardiovascular events and improving clinical outcomes following percutaneous coronary intervention (PCI) for ACS [1,2,3]. International guidelines recommend multiple medications for secondary-prevention including anti-platelet agents, a β-adrenergic receptor blocker (β-blocker), and a statin [4,5,6,7]. The evidence underlying guideline recommendations comes from large trials mostly performed over 20 years ago, during an era prior to routine and/or primary PCI, where thrombolysis was often performed, with greater subsequent mortality compared to the present time. The last 20 years have seen major changes in the management of ACS, resulting in a greater proportion of patients with preserved LV function, primarily due to increased use of primary PCI, and a routine early invasive strategy in NSTEMI [2, 9]

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Results

Conclusion