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. 2021 Dec;35(6):1183-1190.
doi: 10.1007/s10557-020-07128-0. Epub 2020 Dec 18.

Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Acute Coronary Syndrome: Implications for Platelet Reactivity?

Maximilian Tscharre  1   2 , Patricia P Wadowski  2 , Constantin Weikert  2 , Joseph Pultar  2 , Beate Eichelberger  3 , Simon Panzer  3 , Thomas Gremmel  4   5
Affiliations

Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Acute Coronary Syndrome: Implications for Platelet Reactivity?

Maximilian Tscharre et al. Cardiovasc Drugs Ther. 2021 Dec.

Abstract

Background: In patients with acute coronary syndrome (ACS), angiotensin-converting enzyme (ACE) inhibitors are preferred over angiotensin receptor blockers (ARBs). However, in a recent pilot study, treatment with ACE inhibitors was associated with increased platelet reactivity compared to ARBs. Therefore, we sought to investigate the impact of renin-angiotensin-aldosterone system (RAAS) blockade with ACE inhibitors and ARBs on platelet aggregation in patients with ACS undergoing percutaneous coronary intervention.

Methods: On-treatment residual platelet reactivity in response to arachidonic acid (AA), adenosine diphosphate (ADP), SFLLRN, AYPGKF, and collagen was assessed by multiple electrode aggregometry (MEA) in 197 ACS patients on dual antiplatelet therapy (DAPT) with aspirin and either prasugrel or ticagrelor.

Results: One hundred sixty-five (83.7%) patients were treated with ACE inhibitors, 32 (16.3%) with ARBs. On-treatment residual AA- and ADP-inducible platelet reactivity was significantly higher in patients with ACE inhibitors (both p < 0.05). Likewise, SFLLRN was significantly higher in patients with ACE inhibitors (p = 0.036) and there was a trend for higher AYPGKF- and collagen-inducible platelet reactivity (p = 0.053 and p = 0.082). The incidence of high on-treatment residual platelet reactivity AA was significantly higher in patients with ACE inhibitors (52 [31.5%] vs. 3 [9.4%] patients; p = 0.019).

Conclusion: ACE inhibitors are associated with increased on-treatment residual platelet reactivity in ACS patients with potent DAPT. Further clinical trials are needed to elucidate the role of RAAS blockade with ACE inhibitors and ARBs in ACS patients treated according to current standards.

Keywords: Acute coronary syndromes; Angiotensin receptor blockers; Angiotensin-converting enzyme inhibitors; Multiple electrode aggregometry; Platelet reactivity.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Aggregation units (AU) by multiple electrode aggregometry (MEA) in response to AA (panel a), ADP (panel b), SFLLRN (panel c), AYPGKF (panel d), and collagen (panel e) stratified for patients with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Cut-off values for high on-treatment residual platelet reactivity are indicated by the dashed lines. The boundaries of the box show the lower and upper quartile of data, and the line inside the box represents the median. Whiskers are drawn from the edge of the box to the highest and lowest values that are outside the box but within 1.5 times the box length
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