ACE/ARBs in Acute MI Patients With Renal Dysfunction

Apr 07, 2016
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Authors:
Evans M, Carrero JJ, Szummer K, et al.
Citation:
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Myocardial Infarction Patients With Renal Dysfunction. J Am Coll Cardiol 2016;67:1687-1697.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is the impact of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) treatment after acute myocardial infarction (AMI) on outcomes across the entire spectrum of estimated glomerular filtration rates (eGFRs)?

Methods:

The investigators evaluated discharge and continuous follow-up data on ACEI/ARB use among AMI survivors (2006-2009) included in a large Swedish registry. The association between ACEI/ARB treatment and outcomes (mortality, MI, stroke, and acute kidney injury [AKI]) was studied using Cox proportional hazards models (intention-to-treat and as treated).

Results:

In total, 45,697 patients (71%) were treated with ACEI/ARB. Three-year mortality was 19.8% (17.4 % of ACEI/ARB users and 25.4 % of nonusers). In adjusted analysis, significantly better survival was observed for patients treated with ACEI/ARB (3-year hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.77-0.83). The survival benefit was consistent through all kidney function strata, including dialysis patients. Overall, those treated with ACEI/ARB also had lower 3-year risk for MI (HR, 0.91; 95% CI, 0.87-0.95), whereas treatment had no significant impact on stroke risk. The crude risk for AKI was in general low (2.5% and 2.0% for treated and nontreated, respectively) and similar across eGFR categories, but significantly higher with ACEI/ARB treatment. However, the composite outcome of AKI and mortality favored ACEI/ARB treatment.

Conclusions:

The authors concluded that treatment with ACEI/ARB after AMI was associated with improved long-term survival.

Perspective:

This study reports that among MI patients, treatment with either ACEI or ARB was associated with better survival as compared to no treatment across all renal function strata considered, regardless of the presence of left ventricular systolic dysfunction, heart failure, diabetes, or hypertension. However, ACEI/ARB treatment also resulted in a higher risk of AKI in patients with a low eGFR. Even though adverse events such as AKI may develop with the use of ACEI/ARB (close monitoring and dose adjustment therefore are needed), the overall benefit of using these drugs in patients with impaired renal function appears to outweigh the risks.

Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Glomerular Filtration Rate, Mortality, Myocardial Infarction, Receptors, Angiotensin, Renal Dialysis, Risk, Secondary Prevention, Stroke, Survivors


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