Comparative effect of angiotensin converting enzyme inhibitor versus angiotensin ii type i receptor blocker in acute myocardial infarction with non-obstructive coronary arteries; from the Korea Acute Myocardial Infarction Registry — National Institute of Health

Abstract

Background: Selecting angiotensin converting enzyme inhibitor (ACEI) or angiotensin II type I receptor blocker (ARB) in patients diagnosed as acute myocardial infarction (AMI) with non-obstructive coronary arteries (MINOCA) is not established. The purpose of this study is to compare the clinical effect of ACEI vs. ARB in MINOCA patients. Methods and results: A total of 273 patients between November 2011 to June 2015, diagnosed with MINOCA who were registered in the Korea AMI Registry-National Institute of Health were enrolled. Patients were divided into ACEI (n = 112) and ARB groups (n = 161). The primary endpoint was cumulative incidence of major adverse cardiac events (MACE) defined as cardiac death, recurrent MI, any new revascularization during 2 years 2 clinical follow-up. Secondary endpoint was heart failure requiring re-hospitalization. Propensity score matching analysis was done. The incidence of primary endpoint was similar (10.4% vs. 15.6%, HR: 0.65; 95% CI: 0.29-1.47; p = 0.301) among both groups. However, the incidence of recurrent MI was significantly lower in ACEI group compared to ARB group (2.1% vs. 10.4%, HR: 0.18, 95% CI: 0.04-0.86; p = 0.031). Conclusions: In the present study, the risk and incidence of MACE was similar between ACEI and ARB therapy in MINOCA patients. However, ACEI significantly reduced the risk of recurrent MI. Further larger scale multi-center randomized clinical trials are needed to clarify the proper use of renin angiotensin aldosterone system blocker in these patients.

Práticas Clínicas Aplicadas a Pacientes Com Infarto Do Miocárdio Sem Obstrução De Artéria Coronária (Minoca)

“…Conforme os achados, 87,5% (n=7) dos estudos abordaram estratégias terapêuticas farmacológicas, (14)(15)(16)(17)(19)(20)(21) apenas um estudo abordou estratégia de diagnóstico de causa adjacente (18) e não houve estudos que abordassem estratégias não medicamentosas para pacientes após diagnóstico de MINOCA.…”

“…Por outro lado, o uso de inibidores do sistema renina-angiotensina-aldosterona (SRAA) foi comprovado como benéfico em três estudos (37,5%), (15,19,21) um estudo obteve evidência de que os inibidores da enzima conversora de angiotensina (IECA) são a melhor opção em comparação aos bloqueadores do receptor da angiotensina II (BRA), por reduzir reincidência de infarto, salvo contraindicações. ( 19) Além disso, 62,5% (n=5) dos estudos selecionados fazem citação aos inibidores de SRAA como estratégia terapêutica favorável para MINOCA .…”

“…( 19) Além disso, 62,5% (n=5) dos estudos selecionados fazem citação aos inibidores de SRAA como estratégia terapêutica favorável para MINOCA . (14)(15)(16)19,21) Apesar disso, 75% (n=6) dos artigos mostraram que pacientes com MINOCA recebiam menos medicamentos preventivos em relação a pacientes com infarto por obstrução coronariana. (14)(15)(16)(17)20,21) Ainda nesse contexto, seis estudos, afirmaram que há variabilidade na condução clínica desses pacientes.…”

“…(14)(15)(16)(17)20,21) Ainda nesse contexto, seis estudos, afirmaram que há variabilidade na condução clínica desses pacientes. (14)(15)(16)(17)(18)(19)(20)21) Ademais, foi possível verificar em 37,5% (n=3) dos estudos, alta incidên-cia de pacientes que receberam alta hospitalar sem elucidação da causa adjacente da MINOCA. (14,16,20) Também foi exposto por 75% (n=6) dos artigos, que pacientes com MINOCA podem apresentar desfechos clínicos desfavoráveis, com eventos cardiovasculares maiores que incluem mortalidade por todas as causas, morte cardíaca, acidente vascular encefálico e reinfarto do miocárdio.…”

Randomized Evaluation of Beta Blocker and ACE-Inhibitor/Angiotensin Receptor Blocker Treatment for Post Infarct Angina in Patients With Myocardial Infarction With Non-obstructive Coronary Arteries: A MINOCA-BAT Sub Study Rationale and Design

“…Regarding medical management of these patients, clinical registry based studies suggest MINOCA patients are often less likely to receive secondary preventive medications when compared to MICAD patients (7)(8)(9). However, studies have reported benefits of ACEI/ARB therapy (10)(11)(12)(13), statin therapy (11,14), and beta blocker (15) therapy in MINOCA. In particular, Lindahl et al (13) using data from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry of 9,136 MINOCA patients showed that 24% experienced a Major Adverse Coronary Events (MACE) during a mean follow-up period of 4.1 years.…”