#VisualAbstract: Effectiveness of sacubitril-valsartan in post-myocardial infarction management compared to ramipril

1. In patients with acute myocardial infarction, Sacubitril-valsartan was not associated with a significantly lower incidence of death from cardiovascular causes compared to patients receiving ramipril.

2. In patients with acute myocardial infarction, treatment with sacubitril-valsartan did not result in significantly lower rates of incident heart failure than did treatment with ramipril.

Evidence Rating Level: 1 (Excellent)

Study Rundown: In the management of acute myocardial infarction, angiotensin-converting enzyme (ACE) inhibitors are often used to reduce the risk of fatal cardiovascular events and heart failure. Sacubitril-valsartan has been proposed as a new treatment for the management of myocardial infarction, as it has been shown to reduce the risk of clinical deterioration in the setting of heart failure. There is a gap in knowledge as to understanding the effect of Sacubitril-valsartan in patients with acute myocardial infarction. This study found that treatment with sacubitril-valsartan did not result in a significantly lower risk of death from cardiovascular causes or incident heart failure than did treatment with ramipril. This study was limited by patients discontinuing their assigned medications due to hypotension and cough. Nevertheless, these study’s findings are significant, as they demonstrate that sacubitril-valsartan is not more effective than ramipril in preventing incident heart failure or death from cardiovascular causes in patients post-myocardial infarction.

Click to read the study in NEJM

Relevant Reading: Drawing Boundaries around PARADISE

In-Depth [randomized control trial]: This randomized control trial included 5661 patients; 2830 in the sacubitril-valsartan treatment group and 2831 in the ramipril treatment group. Patients without a history of heart failure were eligible if they had a myocardial infarction within 0.5 to 7 days before presentation. Patients who displayed clinical instability, eGFR < 30 ml/min, serum potassium greater than 5.2 mmol/liter, or an inability to take an ACE inhibitor or ARB were excluded from the study. The primary outcomes measured were death from cardiovascular causes or incident heart failure, including hospitalization for heart failure and outpatient episodes of symptomatic heart failure. Outcomes in the primary analysis were assessed via Cox proportional hazards regression model. Between the two treatment groups, death from cardiovascular causes occurred in 10.9% of patients in the sacubitril-valsartan group and 11.8% of patients in the ramipril group (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.78 to 1.07). Episodes of heart failure occurred in 11.9% of patients in the sacubitril-valsartan group and 13.2% of patients in the ramipril group (HR, 0.90; 95% CI, 0.78 to 1.04). Overall, this study determined that there was no significant benefit of sacubitril-valsartan compared to ramipril with respect to measured primary outcomes of death from cardiovascular causes or incident heart failure in the management of post-myocardial infarction patients.

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