Long-term effectiveness of ACE inhibitors or angiotensin receptor blockers in myocardial infarction with preserved left ventricular ejection fraction

TL;DR

This study finds that ACE inhibitors or angiotensin receptor blockers do not significantly benefit heart attack patients with normal heart function over five years.

Contribution

The study is the first to evaluate long-term benefits of ACEi/ARBs in myocardial infarction patients with preserved left ventricular ejection fraction using real-world data.

Findings

The 5-year risk of a composite outcome (death, heart attack, heart failure) was 7.8% in ACEi/ARB users and 8.1% in non-users.

After adjusting for adherence, the risk was 6.5% in ACEi/ARB users and 6.7% in non-users.

No significant benefit of ACEi/ARB treatment was observed in patients with preserved left ventricular ejection fraction.

Abstract

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are effective in the long-term treatment of myocardial infarction with reduced left ventricular ejection fraction (LVEF). However, it is unknown whether there is a benefit in myocardial infarction with preserved LVEF (≥50%).

We used Swedish healthcare registries to emulate a target trial of ACEi/ARBs vs. no ACEi/ARBs for the prevention of a composite outcome (death, myocardial infarction, or heart failure) and its individual components among individuals under 75 years with myocardial infarction and LVEF ≥ 50% between September 2010 and June 2021. We estimated observational analogues of the intention-to-treat effect and the per-protocol effect with confounding adjustment via inverse probability weighting. The 10 697 individuals in the ACEi/ARB group were on average older (median 61 vs. 60 years) and more likely to be male (80.2% vs. 75.3% male) than the 4730 individuals in the no ACEi/ARB group. The estimated 5-year risk of the composite outcome was 7.8% (95% confidence interval 7.1%, 8.5%) in the ACEi/ARB group and 8.1% (7.0%, 9.3%) in the no ACEi/ARB group; risk difference −0.3% (−1.6%, 1.0%). After adjustment for adherence, the risk of the composite outcome was 6.5% (5.9%, 7.2%) in the ACEi/ARB group and 6.7% (5.6%, 8.1%) in the no ACEi/ARB group; risk difference −0.2% (−1.7%, 1.0%).

The estimated risk of a composite of death, myocardial infarction or heart failure was similar in recipients and non-recipients of ACEi/ARB. Our estimates suggest ACEi/ARB treatment in myocardial infarction with preserved LVEF does not confer a benefit.

Graphical Abstract

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