Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
Pharmacotherapy. 2021 Dec;41(12):988-997. doi: 10.1002/phar.2624. Epub 2021 Sep 22.
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.
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).
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).
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.
肾素-血管紧张素-醛固酮系统抑制剂（RAASIs）被推荐用于大多数冠心病（CAD）患者。然而，在指南之间存在争议，即哪些 CAD 患者从这些药物中获益最大。本研究调查了 RAASIs 与当代 CAD 患者心血管结局和急性肾损伤之间的关联。
纳入 2012 年 4 月 1 日在加拿大安大略省存活的年龄≥65 岁的 CAD 患者。结局包括主要不良心血管事件（MACE：心血管死亡、心肌梗死（MI）、不稳定型心绞痛、卒中和冠状动脉血运重建）和 4 年内发生的急性肾损伤（AKI）住院。使用逆概率治疗加权 Cox 比例风险回归模型比较了接受和未接受 RAASIs（血管紧张素转换酶抑制剂或血管紧张素 II 受体阻滞剂）治疗的患者的每种结局的发生率。
共确定了 165058 例 CAD 患者（平均年龄 75 岁，65.5%为男性，64.7%接受 RAASIs 治疗）。经过逆概率加权后，与未接受 RAASIs 治疗的患者相比，接受 RAASIs 治疗的患者 MACE 发生率较低（17.6%比 18.2%，风险比[HR]：0.96，95%置信区间：0.93-0.99）。然而，与未接受 RAASIs 治疗的患者相比，接受 RAASIs 治疗的患者 AKI 发生率较高（1.7%比 1.5%，HR：1.14，95%置信区间：1.02-1.29）。与无既往 MI 的患者相比（HR：1.00，95%CI：0.97-1.04，交互 p < 0.01），有既往 MI 的患者的 MACE 降低幅度更大（HR：0.87，95%CI：0.82-0.92）。与无既往 MI 的患者相比（HR：1.37，95%CI：1.19-1.57，交互 p < 0.01），有既往 MI 的患者 AKI 降低幅度较小（HR：0.82，95%CI：0.66-1.00）。
本研究支持在 CAD 患者中继续使用 RAASIs，尽管获益的幅度似乎小于先前试验观察到的幅度。高危患者，特别是有既往 MI 的患者，似乎从 RAASIs 中获益最大。
