The in-hospital administration of sacubitril/valsartan in acute myocardial infarction: A meta-analysis

Abstract

There is a need to address the evidence gap regarding the in-hospital administration of sacubitril/valsartan in acute myocardial infarction patients. After searching MEDLINE, Google Scholars and Scopus, a random-effects meta-analysis of randomized controlled trials comparing the in-hospital administration of the angiotensin receptor-neprilysin inhibitors (ARNis) versus the standard therapy in patients with reduced heart failure due to myocardial infarction was performed. The primary outcome was major adverse cardiovascular events. All-cause mortality, cardiac death, rehospitalization for heart failure, non-fatal myocardial infarction (MI), changes in left ventricular ejection fraction, left ventricular volumes, N terminal pro brain natriuretic peptide and adverse events were the secondary endpoints. Nine studies (eight randomized controlled trials and one echo-substudy) with a total 6597 individuals (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker: 3300 patients vs. ARNis: 3297 patients) were included for quantitative analysis. Median follow-up was 6 months. Patients receiving an in-hospital coadministration of ARNi had a lower risk of major cardiovascular event [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.32-0.63, P < 0.0001] and lower rate of repeat rehospitalization for heart failure (OR 0.40, 95% CI 0.26-0.62, P < 0.0001), compared with a standard regimen. Additionally, left ventricle volumes were significantly lower in the ARNi group [left ventricular end-diastolic volume, mean difference (MD) 11.48 mL, 95% CI 6.10-16.85, P < 0.0001; left ventricular end-systolic volume, MD 7.09 mL, 95% CI 2.89-11.29, P = 0.0009] with a significant change in left ventricular ejection fraction (MD 3.07, 95% CI 1.61-4.53, P < 0.0001), compared with standard therapy. No significant differences were observed in terms of cardiac death, all cause of mortality, non-fatal myocardial infarction and N terminal pro brain natriuretic peptide. Higher rates of iatrogenic hypotensive events were observed in the ARNi group compared with the standard therapy (OR 1.42, 95% CI 1.26-1.60, P value < 0.00001). In patients with acute myocardial infarction related heart failure, the in-hospital administration of ARNis was associated with a reduced risk of major cardiovascular events and re-hospitalization for heart failure, as well as cardiac remodelling, but higher rates of hypotensive events compared with standard therapy.

Keywords: acute myocardial infarction; angiotensin receptor‐neprylisin Inihibitors; heart failure; medical therapy; sacubitril; valsartan.

Figure 1

PRISMA 2020 flow diagram of the searching strategy.

Figure 2

MACE. Primary (A) and sensitivity (B) analysis. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 3

All cause of mortality. Primary (A) and sensitivity (B) analysis. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 4

Cardiac death. Primary (A) and sensitivity (B) analysis. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 5

Rehospitalization for heart failure. Primary (A) and sensitivity (B) analysis. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 6

Non‐fatal MI. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 7

Left ventricular ejection fraction. Primary (A) and sensitivity (B) analysis. ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 8

Left ventricular end‐diastolic volume (A) and left ventricular end‐systolic volume (B). ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.

Figure 9

Overall adverse events (A), hypotension (B) and renal impairment (C). ACEi, angiotensin‐converting enzyme inhibitors; ARB, angiotensin receptor blockers; ARNi, angiotensin receptor‐neprilysin inhibitor; CI, confidence interval; M‐H, Mantel–Haensel.