ST elevation myocardial infarction inhibition of the renin-angiotensin-aldosterone system at discharge
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Angiotensin Converting Enzyme (ACE) Inhibition remains first line therapy among STEMI patients, particularly those with poor left ventricular function following ST elevation myocardial infarction. The benefits of ACE inhibition are clear among patients with an anterior myocrdial infarction and are less clear among patients with non-anterior myocardial infarction. Patients who cannot tolerate an ACE inhibitor (for example they develop a cough) can be treated with an Angiotensin Receptor Blocker (ARB). In addition to an ACE inhibitor, if a patient has symptomatic heart failure or a left ventricular ejection fraction < 40% and does not have impaired renal function or hyperkalemia, then long-term aldosterone blockade should be administered.
Angiotensin Converting Enzyme (ACE) Inhibition
Aldosterone Inhibition
Data regarding the safety and efficacy aldosterone inhibition is derived from trials of heart failure that enrolled patients with a prior MI.
- RALES study (Randomized Aldactone Evaluation Study)
- Among patients with New York Heart Association class III to IV heart failure, treatment with spironolactone at an initial dose of 25 mg daily with an increase to 50 mg PO daily was associated with a 11% ARD (24% RRR) in all-cause mortality over 2 years despite co-administration of an ACE inhibitor in 95% of the patients. [1] In so far as 55% of the patients developed heart failure on the basis of ischemic heart disease, these results may be applicable to patients with STEMI.
- EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study)
- In contrast to RALES, this study focused specifically on post-MI patients (n=6632). Despite co-administration of ACE inhibitors to these post-MI patients with either a ejection fraction < 40% or diabetes, eplerenone at a dose of 50 mg daily was associated with a significant reduction in all cause mortality, cardiovascular mortality, and cardiac hospitalizations [2]
While RALES and EPHESUS support the long-term administration of an aldosterone antagonists in post_MI patients with an EF < 40% or heart failure, the following are contraindications:
- Creatinine > 2.5 mg/dl in men
- Creatinine (Cr) > 2.0 mg/dl in women
- Potassium (K+) > 5.0 mEq/L.
- A relative contraindication is a creatinine clearance < 50 mL/min.
Angiotensin Receptor Blockade (ARB)
The safety and efficacy of Angiotensin Receptor Blockade (ARB) in the setting of STEMI has not been as extensively evaluated as ACE inhibitors.
- OPTIMAAL (Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan)
- Losartan 50 mg once daily did not differ from captopril at a dose of 50 mg PO three times daily with respect to all cause mortality. Numerically but not significantly significant results were found in favor of captopril. [3]
- VALIANT trial (Valsartan in Acute Myocardial Infarction Trial)
- Post MI patients with LV dysfunction were randomized to receive either valsartan at a dose of 160 mg PO twice daily versus captopril 50 mg 3 times daily versus the combination of the two agents at doses of valsartan 80 mg twice daily plus captopril 50 mg 3 times daily plus. [4] Two year mortality did not differ between the three arms 19.9% for valsartan, 19.5% for captopril, and 19.3% in the combination arm (p=NS). Valsartan was associated with a higher rate of hypotension and renal dysfunction.
ACE Versus ARB Inhibition
ACE inhibitors remain the first line of therapy given the large randomized trial data demonstrating their safety and efficacy following STEMI. Among STEMI patients with poor LV function who are intolerant to ACE inhibitors, Valsartan monotherapy at a dose 160 mg twice daily. Side effects and cost should be taken into consideration if a decision is made to administer Valsartan instead of an ACE inhibitor.
ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: ACE Inhibitors (DO NOT EDIT)[5]
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Class I1. ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF less than or equal to 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. (Level of Evidence: A) 2. ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. (Level of Evidence: B) Class IIa1. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Level of Evidence: B) |
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ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: Angiotensin Receptor Blockers (DO NOT EDIT)[5]
| “ |
Class I1. Use of angiotensin receptor blockers is recommended in patients who are intolerant of ACE inhibitors and have HF or have had an MI with LVEF less than or equal to 40%. (Level of Evidence: A) 2. It is beneficial to use angiotensin receptor blocker therapy in other patients who are ACE-inhibitor intolerant and have hypertension. (Level of Evidence: B) Class IIb1. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable. (Level of Evidence: B) |
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ACC / AHA Guidelines- Recommendations for Renin-Angiotensin-Aldosterone System Blockers: Aldosterone Blockade (DO NOT EDIT)[5]
| “ |
Class I1. Use of aldosterone blockade in post-MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of less than or equal to 40%, and have either diabetes or HF. (Level of Evidence: A) |
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Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [6]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [5]
References
- ↑ Pitt B, Zannad F, Remme WJ, et al, for the Randomized Aldactone: Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709-17.
- ↑ Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.
- ↑ Dickstein K, Kjekshus J, for the OPTIMAAL Steering Committee of the OPTIMAAL Study Group. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet 2002;360:752-60.
- ↑ Pfeffer MA, McMurray JJ, Velazquez EJ, et al, for the Valsartan in Acute Myocardial Infarction Trial Investigators. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003;349:1893-906.
- ↑ 5.0 5.1 5.2 5.3 Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
|month=ignored (help)