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Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction.

ABSTRACT: Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.

SUBMITTER: Wong EC

PROVIDER: S-EPMC8483484 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveTo investigate the association between treatment with an angiotensin receptor blocker and clinical outcomes in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function.DesignA prospective cohort study using data from a nationwide large scale registry.Setting53 hospitals involved in treatment of acute myocardial infarction in Korea.ParticipantsBetween November 2005 and September 2010, we studied 6698 patients with ST segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and had a left ventricular ejection fraction ≥ 40%.Main outcome measuresCardiac death or myocardial infarction. Patients were divided into an angiotensin receptor blocker group (n=1185), an angiotensin converting enzyme (ACE) inhibitor group (n=4564), and a group who did not receive any renin angiotensin system blocker (n=949). Propensity score matching analysis was also performed.ResultsCardiac death or myocardial infarction occurred in 21 patients (1.8%) in the angiotensin receptor blocker group, 77 patients (1.7%) in the ACE inhibitor group, and 33 patients (3.5%) in the no renin angiotensin system blocker group. After propensity score matching (1175 pairs), there was no significant difference in the rate of cardiac death or myocardial infarction between the angiotensin receptor blocker group and ACE inhibitor group (21 (1.8%) v 23 (2.0%), adjusted hazard ratio 0.65, 95% confidence interval 0.30 to 1.38; P=0.65). The angiotensin receptor blocker group had a lower rate of cardiac death or myocardial infarction than the no renin angiotensin system blocker group in matched populations (803 pairs) (14 (1.7%) v 25 (3.1%), 0.35, 0.14 to 0.90; P=0.03).ConclusionAngiotensin receptor blocker showed beneficial effects comparable with ACE inhibitors in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function. Angiotensin receptor blockers could be used as an alternative to ACE inhibitors in such patients.

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Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction.

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