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Original article
DOI: 10.1016/j.rec.2019.02.012
Available online 18 May 2019
Impact of renin-angiotensin system blockade on the prognosis of acute coronary syndrome based on left ventricular ejection fraction
Impacto del bloqueo del sistema renina-angiotensina en el pronóstico del síndrome coronario agudo en función de la fracción de eyección
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Sergio Raposeiras-Roubína,
Corresponding author
raposeiras26@hotmail.com

Corresponding author: Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Estrada Clara Campoamor 341, 36212 Vigo, Pontevedra, Spain.
, Emad Abu-Assia, María Cespón-Fernándeza, Borja Ibáñezb, José Manuel García-Ruizb, Fabrizio D’Ascenzoc, Jose Paulo Simao Henriquesd, Jorge Saucedoe, Berenice Caneiro-Queijaa, Rafael Cobas-Paza, Isabel Muñoz-Pousaa, Stephen B. Wiltonf, José Ramón González Juanateyg, Wouter J. Kikkertd, Iván Núñez-Gilh, Albert Ariza-Soléi, Xiantao Songj, Dimitrios Alexopoulosk, Christoph Liebetraul, Tetsuma Kawajim, Fiorenzo Gaitac, Zenon Huczekn, Shao-Ping Nieo, Yan Yano, Toshiharu Fujiip, Luis Correiaq, Masa-aki Kawashirir, Sasko Kedevs, Danielle Southernf, Emilio Alfonsoh, Belén Terolh, Alberto Garayi, Dongfeng Zhangj, Yalei Chenj, Ioanna Xanthopoulouk, Neriman Osmanl, Helge Möllmannl, Hiroki Shiomim, Francesca Giordanac, Michal Kowaran, Krzysztof Filipiakn, Xiao Wango, Jing-Yao Fano, Yuji Ikarir, Takuya Nakahayshir, Kenji Sakatar, Masakazu Yamagishir, Oliver Kalpaks, Andrés Íñiguez-Romoa
a Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
b Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain
c Cardiology Department, San Giovanni Battista Molinette Hospital, Turin, Italy
d Cardiology Department, University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
e Cardiology Department, NorthShore University Hospital, Chicago, Illinois, United States
f Cardiology Department, Libin Cardiovascular Institute of Alberta, Calgary, Canada
g Servicio de Cardiología, Hospital Clínico, Santiago de Compostela, A Coruña, Spain
h Servicio de Cardiología, Hospital San Carlos, Madrid, Spain
i Servicio de Cardiología, Hospital Bellvitge, Barcelona, Spain
j Cardiology Department, Anzhen Hospital, Beijing, China
k Cardiology Department, University Patras Hospital, Patras, Greece
l Cardiology Department, Kerckhoff Heart and Thorax Center, Frankfurt, Germany
m Cardiology Department, University Graduate School of Medicine, Kyoto, Japan
n Cardiology Department, University Clinical Hospital, Warsaw, Poland
o Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
p Cardiology Department, Tokai University School of Medicine, Tokai, Japan
q Cardiology Department, Hospital Sao Rafael, Salvador, Brazil
r Cardiology Department, University Graduate School of Medicine, Kanazawa, Japan
s Cardiology Department, University Clinic of Cardiology, Skopje, Macedonia
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Received 02 October 2018. Accepted 21 February 2019
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Tables (2)
Table 1. Baseline characteristics according to prescription or not of ACEI/ARB at discharge
Table 2. Analyses to assess the prognostic impact of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on 1-year mortality
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Abstract
Introduction and objectives

For patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.

Methods

Data from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.

Results

Among 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P=.012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF> 40% (P value for treatment-by-LVEF interaction=.008). For patients with LVEF> 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P=.031).

Conclusion

The benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF> 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF> 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.

Keywords:
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Acute coronary syndromes
Percutaneous coronary intervention
Mortality
Abbreviations:
ACEI
ACS
ARB
DAPT
HF
LVEF
Resumen
Introducción y objetivos

No está clara la asociación entre los inhibidores de la enzima de conversión de la angiotensina (IECA) o los antagonistas del receptor de la angiotensina II (ARA-II) y la mortalidad de los pacientes con síndrome coronario agudo (SCA) sometidos a intervención coronaria percutánea (ICP) con fracción de eyección del ventrículo izquierdo (FEVI) conservada. Nuestro objetivo es determinar dicha asociación en pacientes con FEVI conservada o reducida.

Métodos

Se analizaron datos procedentes del registro BleeMACS. El objetivo principal fue la mortalidad a 1 año. Se aplicaron ponderación por la probabilidad inversa del tiempo de supervivencia y ajustes por regresión de Cox, puntuación de propensión y variables instrumentales.

Resultados

De los 15.401 pacientes con SCA sometidos a ICP, se prescribieron IECA/ARA-II al 75,2%. Se produjeron 569 muertes (3,7%) durante el primer año tras el alta hospitalaria. Después del ajuste multivariado, los IECA/ARA-II se asociaron con menor mortalidad, pero solo en los pacientes con FEVI ≤ 40% (HR=0,62; IC95%, 0,43-0,90; p=0,012). Con los IECA/ARA-II, la reducción del riesgo relativo de la mortalidad estimada fue del 46,1% en los pacientes con FEVI ≤ 40% y del 15,7% en aquellos con FEVI> 40% (pinteracción=0,008). En los pacientes con FEVI> 40%, los IECA/ARA-II se asociaron con menor mortalidad solo por infarto agudo de miocardio con elevación del segmento ST (HR=0,44; IC95%, 0,21-0.93; p=0,031).

Conclusiones

El beneficio de los IECA/ARA-II en mortalidad tras ICP por SCA se concentra en pacientes con FEVI ≤ 40% y aquellos con FEVI> 40% e infarto agudo de miocardio con elevación del segmento ST. Se precisan estudios contemporáneos que analicen el impacto de los IECA/ARA-II en pacientes con SCA sin elevación del segmento ST y FEVI> 40%.

Palabras clave:
Inhibidores de la enzima de conversión de la angiotensina
Antagonistas del receptor de la angiotensina II
Síndrome coronario agudo
Intervención coronaria percutánea
Mortalidad

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