Renin‐angiotensin‐aldosterone system inhibitors and major cardiovascular events and acute kidney injury in patients with coronary artery disease

Abstract

Background Renin‐angiotensin‐aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD. Methods Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment‐weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers). Results There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse‐probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93–0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02–1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82–0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97–1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66–1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19–1.57, interaction p < 0.01). Conclusions This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High‐risk patients, particularly those with prior MI, appear to benefit the most from RAASIs.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

“…The lack of overall benefit of RAASi in lower risk populations likely reflects both baseline comorbidities and levels of concurrent pharmacotherapies with other evidence-based therapies for CCD. 20,21…”

Retrospective Evaluation of In-Hospital and Thirty-Month Mortality Parameters in Cases of Acute Coronary Syndrome

“…In subgroup analyzes, it was determined that the decrease in MACE was more pronounced in those with a previous history of MI. 32 As for statins, whose positive effects have been shown in large studies in primary and secondary prevention of coronary artery disease, it was detected that they were used in STEMI, NSTEMI and UAP at rates of 92%, 95%, and 83% respectively, during the in-hospital period, and were prescribed at rates of 89%, 92%, and 86%, respectively, in STEMI, NSTEMI, and UAP patients at discharge. Large statin studies in ACS cases can be listed as PROVE-IT, MIRACLE and A to Z.…”