Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
Laboratory for Mechanisms and Therapies of Heart Diseases, School of Pharmacy, Tianjin Medical University, Tianjin, China.
Eur Heart J Qual Care Clin Outcomes. 2023 Dec 22;9(8):785-795. doi: 10.1093/ehjqcco/qcad006.
In acute coronary syndrome (ACS) patients without advanced renal dysfunction [estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2], early (within 24 h of admission) angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) is the guideline-directed medical therapy. The clinical efficacy of early ACEI/ARB therapy among ACS patients with advanced renal dysfunction remains unclear.
Among 184 850 ACS patients hospitalized from July 2014 to December 2018 in the Chinese National Electronic Disease Surveillance System Platform (CNEDSSP) cohort and 113 650 ACS patients enrolled from November 2014 to December 2019 in the Improving Care for Cardiovascular Disease in China-ACS Project (CCC-ACS) cohort, we identified 3288 and 3916 ACS patients with admission eGFR < 30 mL/min/1.73 m2 [2647 patients treated with ACEI/ARB (36.7%)], respectively. After 1:1 propensity score matching (PSM) in each cohort, Kaplan-Meier analysis showed that early ACEI/ARB use was associated with a 39% [hazard ratio (HR): 0.61, 95% confidence interval (95% CI): 0.45-0.82] and a 34% (HR: 0.66, 95% CI: 0.46-0.95) reduction in in-hospital mortality in CNEDSSP and CCC-ACS cohorts, respectively, which was consistent in multiple sensitivity analyses. A random effect meta-analysis of the two cohorts after PSM revealed a 32% reduction (risk ratio: 0.68, 95% CI: 0.55-0.84) in in-hospital mortality among ACEI/ARB users.
Based on two nationwide cohorts in China in contemporary practice, we demonstrated that ACEI/ARB therapy initiated within 24 h of admission is associated with a reduction in in-hospital mortality in ACS patients with advanced renal dysfunction.
CCC-ACS project was registered at URL: https://www.clinicaltrials.gov. (Unique identifier: NCT02306616).
在无严重肾功能障碍的急性冠状动脉综合征（ACS）患者中（估计肾小球滤过率[eGFR]＜30 ml/min/1.73 m2），指南推荐早期（入院后 24 小时内）使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB）。然而，在伴有严重肾功能障碍的 ACS 患者中，早期 ACEI/ARB 治疗的临床疗效尚不清楚。
在中国国家电子疾病监测系统平台（CNEDSSP）队列中，我们纳入了 2014 年 7 月至 2018 年 12 月期间住院的 184850 例 ACS 患者，在改善中国心血管疾病治疗-ACS 项目（CCC-ACS）队列中，我们纳入了 2014 年 11 月至 2019 年 12 月期间住院的 113650 例 ACS 患者。我们在 CNEDSSP 队列中识别出 3288 例和 CCC-ACS 队列中识别出 3916 例入院时 eGFR＜30 ml/min/1.73 m2 的 ACS 患者[分别有 2647 例患者接受 ACEI/ARB（36.7%）]。在每个队列中进行 1:1 倾向评分匹配（PSM）后，Kaplan-Meier 分析表明，早期使用 ACEI/ARB 可使住院死亡率分别降低 39%[风险比（HR）：0.61，95%置信区间（95%CI）：0.45-0.82]和 34%（HR：0.66，95%CI：0.46-0.95），这在多项敏感性分析中是一致的。对 PSM 后两个队列进行的随机效应荟萃分析显示，ACEI/ARB 使用者的住院死亡率降低了 32%（风险比：0.68，95%CI：0.55-0.84）。
基于中国两个全国性队列的当代实践，我们证明了入院 24 小时内开始使用 ACEI/ARB 治疗与伴有严重肾功能障碍的 ACS 患者的住院死亡率降低有关。
CCC-ACS 项目在 URL 注册：https://www.clinicaltrials.gov。（唯一标识符：NCT02306616）。
