Sacubitril/valsartan bests ramipril for secondary prevention in heart attack survivors

For survivors of an acute myocardial infarction (AMI) with left ventricular systolic dysfunction and pulmonary congestion, secondary prevention with sacubitril/valsartan yields more favourable outcomes than with ramipril, according to a study.

Researchers performed a prespecified analysis of the PARADISE-MI*, a trial that evaluated the efficacy of sacubitril/valsartan (97/103 mg twice daily) against ramipril (5 mg twice daily) for reducing heart failure events following heart attack.

The analysis included 5,661 patients (mean age 63.7 years, 24.1 percent female, 42 percent with diabetes) with AMI complicated by left ventricular systolic dysfunction, pulmonary congestion, or both. A total of 3,759 (87.6 percent) patients with a ST-segment–elevation myocardial infarction (STEMI) and 1,023 (74.7 percent) with non-STEMI underwent reperfusion with percutaneous coronary intervention within 24 hours. Most patients received evidence-based secondary prevention agents, including dual antiplatelet therapy (92 percent), statins (95 percent), and β-blockers (85 percent).

Patients were randomized to either sacubitril/valsartan or ramipril a median of 4.4 days after index AMI (STEMI 76 percent, non-STEMI 24 percent), by which time 89 percent of patients had undergone coronary reperfusion. The prespecified composite coronary outcome included the first occurrence of death from coronary heart disease, nonfatal myocardial infarction, hospitalization for angina, or postrandomization coronary revascularization.

The risk of the composite coronary outcome was 14-percent lower in the sacubitril/valsartan group than in the ramipril group (hazard ratio, 0.86, 95 percent confidence interval [CI], 0.74–0.99; p=0.04) over a median follow-up of 22 months.

Moreover, the rates of the individual components of the composite outcomes were lower in patients on sacubitril/valsartan but were not individually significantly different.

*Prospective ARNI vs ACE Inhibitors Trial to Determine Superiority in Reducing Heart Failure Events After MI