Yang Pei, Han Yang, Lian Cheng, Wu Xinlei
Department of Cardiology, Tangdu Hospital, Air Force Medical University, Xi'an, China.
Department of Cardiology, Xi'an International Medical Center Hospital, Xi'an, China.
Front Cardiovasc Med. 2022 Aug 24;9:988117. doi: 10.3389/fcvm.2022.988117. eCollection 2022.
The angiotensin-receptor neprilysin inhibitor (ARNI) sacubitril/valsartan was shown to be superior to the angiotensin receptor blocker (ARB) valsartan in terms of reversing heart failure classification (NYHA classification), reducing N-terminal pro-brain natriuretic peptide (NT-proBNP) level and cardiovascular mortality in many studies. Yet, the efficacy of ARNI did not come from patients with acute myocardial infarction (AMI).
We searched databases for research published from inception to July 29, 2022, that reported cardiac reverse remodeling (CRR) or security indices. Two reviewers independently screened literature, extracted data, and assessed the risk of bias. Nine studies enrolling 1,369 patients were included to perform a meta-analysis. There were 716 patients in the ARNI group and 653 in the ARB group.
ARNI outperformed ARBs in terms of CRR indices, with striking changes in left ventricular ejection fraction (EF) (MD: 4.12%, 95%CI: 2.36, 5.88, < 0.0001), diameter (MD: -3.40 mm, 95%CI: -4.30, -2.94, < 0.00001, = 0%) and left atrial diameter (MD: -2.41 mm, 95%CI: -3.85, -0.97, = 0.001, = 0%), other indices there showed no significant improvements. The incidences of major adverse cardiac events (RR: 0.47, 95%CI: 0.34-0.65, < 0.00001, = 0%), the heart failure (RR: 0.37, 95%CI: 0.23-0.61, < 0.0001, = 0%), readmission (RR: 0.54, 95%CI: 0.36-0.80, = 0.003, = 29%) in the sacubitril/valsartan group were lower than the ARB group, while the incidences of cardiac death (RR: 0.56, 95%CI: 0.28, 1.09, = 0.09), the myocardial infarction (RR: 0.83, 95% CI: 0.39, 1.77, = 0.63), adverse side effects (RR: 1.67, 95% CI: 0.89, 3.13, = 0.11) showed no difference.
This research indicated that early initiation of sacubitril/valsartan in patients after AMI was superior to ARBs in reducing the risks of major adverse cardiac events, heart failure, readmission, and enhancing left ventricular EF, decreasing diameter, left atrial diameter. As for the other outcomes (the incidences of cardiac death, myocardial infarction, and adverse side effects), sacubitril/valsartan demonstrated no obvious advantage over ARBs.
https://www.crd.york.ac.uk/prospero/, identifier [CRD42022307237].
在多项研究中，血管紧张素受体脑啡肽酶抑制剂（ARNI）沙库巴曲缬沙坦在逆转心力衰竭分级（纽约心脏协会分级）、降低N末端脑钠肽前体（NT-proBNP）水平及心血管死亡率方面，被证明优于血管紧张素受体阻滞剂（ARB）缬沙坦。然而，ARNI的疗效并非来自急性心肌梗死（AMI）患者。
我们检索了从数据库建立至2022年7月29日发表的报告心脏逆向重构（CRR）或安全性指标的研究。两名审阅者独立筛选文献、提取数据并评估偏倚风险。纳入9项研究共1369例患者进行荟萃分析。ARNI组有716例患者，ARB组有653例患者。
在CRR指标方面，ARNI优于ARB，左心室射血分数（EF）有显著变化（MD：4.12%，95%CI：2.36，5.88，P<0.0001），直径（MD：-3.40mm，95%CI：-4.30，-2.94，P<0.00001，I²=0%）和左心房直径（MD：-2.41mm，95%CI：-3.85，-0.97，P=0.001，I²=0%），其他指标未显示出显著改善。沙库巴曲缬沙坦组主要不良心脏事件的发生率（RR：0.47，95%CI：0.34 - 0.65，P<0.00001，I²=0%）、心力衰竭（RR：0.37，95%CI：0.23 - 0.61，P<0.0001，I²=0%）、再入院率（RR：0.54，95%CI：0.36 - 0.80，P=0.003，I²=29%）低于ARB组，而心源性死亡发生率（RR：0.56，95%CI：0.28，1.09，P=0.09）、心肌梗死发生率（RR：0.83，95%CI：0.39，1.77，P=0.63）、不良反应发生率（RR：1.67，95%CI：0.89，3.13，P=0.11）无差异。
本研究表明，AMI后患者早期应用沙库巴曲缬沙坦在降低主要不良心脏事件、心力衰竭、再入院风险以及提高左心室EF、减小直径、左心房直径方面优于ARB。至于其他结局（心源性死亡、心肌梗死和不良反应发生率），沙库巴曲缬沙坦与ARB相比无明显优势。
