BackgroundWhether angiotensin II receptor blocker (ARB) can be an alternative to angiotensin-converting enzyme inhibitor (ACEI) in patients without heart failure (HF) after acute myocardial infarction (MI) remains controversial. The aim of this study was to compare clinical outcomes between initial ARB and ACEI therapy in patients with MI without HF. MethodsBetween 2010 and 2016, a total of 31,013 patients who underwent coronary revascularization for MI with prescription of ARB or ACEI at hospital discharge were enrolled from the Korean nationwide medical insurance data. Patients who had HF at index MI were excluded. The primary outcome was all-cause death. The secondary outcomes included recurrent MI, hospitalization for new heart HF, stoke, and a composite of each outcome. ResultsOf 31,013 patients, ARBs were prescribed in 12,685 (40.9%) and ACEIs in 18,328 (59.1%). Patients receiving ARB had a lower discontinuation rate compared with those receiving ACEI (28.2% versus 43.5%, adjusted hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.31–0.37, p<0.01). During a median follow-up of 2.2 years, 2,480 patients died. The incidence rate of all-cause death in patients receiving ARB and those receiving ACEI was 27.7 and 22.9 per 1,000 person-years, respectively (adjusted HR 1.04; 95% CI, 0.95–1.13; p=0.40). There were no significant differences in the secondary outcomes between patients receiving ARB and those receiving ACEI, except stroke (19.2 vs. 13.6 per 1,000 person-years; adjusted HR 1.17; 95% CI 1.04–1.32; p=0.01). In a subgroup analysis, a higher mortality was observed with ARBs compared to ACEIs in patients with diabetes. ConclusionsIn this nationwide cohort, there was no significant difference in the incidence of all-cause death between ARB and ACEI as discharge medications in patients with MI without HF. ARBs would be an alternative to ACEIs for those intolerant to ACEI therapy.