Use of Renin–Angiotensin System Blockers in Acute Coronary Syndromes

Abstract

Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) initiated after myocardial infarction (MI) reduce mortality and are American College of Cardiology/American Heart Association guideline recommended. Yet the extent to which ACEI/ARB therapy is applied in patients with acute coronary syndrome at hospital discharge is unclear. We performed an observational analysis of 80 241 patients admitted with an acute coronary syndrome and discharged home from 311 U.S. hospitals participating in the Get With the Guidelines-Coronary Artery Disease Program from January 2005 to December 2009. Among the 60,847 patients with an American College of Cardiology/American Heart Association class I indication (left ventricular dysfunction or medical history of heart failure, hypertension, diabetes mellitus, or chronic kidney disease), 49,682 (81.7%) received ACEI/ARB with an increase in the rate of treatment over the study period (76.7%-84.6%; adjusted odds ratio, 1.17; 95% confidence interval, 1.10-1.24; P<0.001, per calendar year). In-hospital coronary artery bypass grafting and renal insufficiency were independently associated with lower use (adjusted odds ratio, 0.55; 95% confidence interval, 0.48-0.63 and adjusted odds ratio, 0.58; 95% confidence interval, 0.52-0.64, respectively). Results from this large U.S. national registry suggest that 1 in 5 eligible patients hospitalized for acute coronary syndrome failed to receive American College of Cardiology/American Heart Association class I guideline-recommended ACEI/ARB therapy, and the use varies by patient factors. In particular, the low likelihood of ACEI/ARB after coronary artery bypass grafting surgery or in patients with renal insufficiency raises concern. These findings highlight an unmet need in this population and provide an incentive for additional quality improvement efforts.