Di Pietro Gianluca, Improta Riccardo, Severino Paolo, D'Amato Andrea, Birtolo Lucia Ilaria, De Filippo Ovidio, Lattanzio Antonio, De Cristofaro Raffaele, Galardo Giacchino, D'Ascenzo Fabrizio, Badagliacca Roberto, Sardella Gennaro, Volterrani Maurizio, Fedele Francesco, Vizza Carmine Dario, Mancone Massimo
Department of Internal Clinical, Anesthesiological, Cardiovascular Sciences, La Sapienza University of Rome, Rome, Italy.
Department of Cardiovascular and Thoracic, Division of Cardiology, Città della Salute e della Scienza Hospital, Turin, Italy.
ESC Heart Fail. 2025 Apr;12(2):998-1012. doi: 10.1002/ehf2.15082. Epub 2024 Oct 29.
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.
有必要填补急性心肌梗死患者院内使用沙库巴曲缬沙坦的证据空白。在检索MEDLINE、谷歌学术和Scopus之后，对比较血管紧张素受体脑啡肽酶抑制剂（ARNI）与标准治疗方案用于因心肌梗死导致心力衰竭患者的院内给药情况的随机对照试验进行了随机效应荟萃分析。主要结局是主要不良心血管事件。全因死亡率、心源性死亡、因心力衰竭再次住院、非致死性心肌梗死（MI）、左心室射血分数、左心室容积、N末端脑钠肽前体的变化以及不良事件为次要终点。纳入9项研究（8项随机对照试验和1项超声亚研究），共6597例个体（血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂：3300例患者 vs. ARNI：3297例患者）进行定量分析。中位随访时间为6个月。与标准治疗方案相比，院内联合使用ARNI的患者发生主要心血管事件的风险较低[比值比（OR）0.45，95%置信区间（CI）0.32 - 0.63，P < 0.0001]，因心力衰竭再次住院的发生率较低（OR 0.40，95% CI 0.26 - 0.62，P < 0.0001）。此外，与标准治疗相比，ARNI组的左心室容积显著降低[左心室舒张末期容积，平均差（MD）11.48 mL，95% CI 6.10 - 16.85，P < 0.0001；左心室收缩末期容积，MD 7.09 mL，95% CI 2.89 - 11.29，P = 0.0009]，左心室射血分数有显著变化（MD 3.07，95% CI 1.61 - 4.53，P < 0.0001）。在心源性死亡、全因死亡率、非致死性心肌梗死和N末端脑钠肽前体方面未观察到显著差异。与标准治疗相比，ARNI组发生医源性低血压事件的发生率更高（OR 1.42，95% CI 1.26 - 1.60，P值< 0.00001）。在急性心肌梗死相关心力衰竭患者中，院内使用ARNI与主要心血管事件和因心力衰竭再次住院的风险降低以及心脏重塑相关，但与标准治疗相比，低血压事件的发生率更高。
