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Angiotensin inhibition after myocardial infarction: does drug class matter?
Wolfgang C Winkelmayer1, Michael A Fischer, Sebastian Schneeweiss
1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02120, USA. wwinkelmayer@partners.org
Insights
Angiotensin receptor blockers (ARBs) and angiotensin converting enzyme-inhibitors (ACEIs) show equal 1-year survival after myocardial infarction (MI) in real-world settings. Despite higher costs, ARB use has significantly increased, lacking demonstrated therapeutic advantage over ACEIs.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Angiotensin converting enzyme-inhibitors (ACEIs) and angiotensin-II-receptor blockers (ARBs) are equally effective in reducing mortality post-myocardial infarction (MI).
- ARBs are significantly more expensive than ACEIs.
- Limited data exist on the comparative use and effectiveness of ACEIs versus ARBs in real-world healthcare settings after MI.
Purpose of the Study:
- To analyze trends in the utilization of ACEIs and ARBs following MI.
- To compare the 1-year survival rates between patients treated with ACEIs and those treated with ARBs after MI.
Main Methods:
- Retrospective cohort study involving Medicare beneficiaries who survived >90 days post-MI.
- Included patients had full prescription drug coverage and initiated either ACEI or ARB therapy within 90 days of MI.
- Assessed temporal changes in drug class use and adjusted 1-year mortality rates between ACEI and ARB users.
Main Results:
- From 1995-2004, 14,190 patients met inclusion criteria (mean age 80, 75% female, 90% white).
- Overall ACEI use was 88%, ARB use was 12%. ARB proportion increased from 2% in 1995 to 25% in 2004 (P<.001).
- Multivariate-adjusted 1-year mortality showed no significant difference between ARB and ACEI users (HR: 1.04; 95% CI: 0.88-1.22).
Conclusions:
- In routine care, 1-year mortality after MI is comparable for Angiotensin Receptor Blocker (ARB) and Angiotensin Converting Enzyme-Inhibitor (ACEI) users.
- The use of more expensive ARBs has risen substantially, reaching 25% of users by 2004, without a clear therapeutic benefit over ACEIs for most patients.
- This trend highlights a potential for cost savings by optimizing ACEI/ARB prescribing patterns in post-MI care.
Background:
Angiotensin converting enzyme-inhibitors (ACEI) and angiotensin-II-receptor blockers (ARB) are equally efficacious in reducing mortality after MI, although the latter are far more costly. Little is known about their relative use after MI in typical care settings, and about their relative effectiveness outside the clinical trial setting.
Objectives:
To assess temporal trends in the relative use of ACEI and ARB after myocardial infarction, and to test for differences in 1-year survival between users of these drug classes.
Design:
Retrospective closed cohort study.
Patients:
Medicare beneficiaries who survived >90 days after myocardial infarction, had full prescription drug coverage, and who filled a prescription for either ACEI or ARB within 90 days of myocardial infarction.
Measurements:
Relative use of ACEI versus ARB over time. Adjusted relative 1-year mortality between ACEI and ARB users.
Results:
Between 1995 and 2004, 14,190 patients met inclusion criteria. Mean age was 80 years, 75% were female, and 90% were white. Overall, 88% received an ACEI, and 12% an ARB, with the proportion receiving an ARB increasing from 2% (1995) to 25% (2004; P<.001). Multivariate-adjusted 1-year mortality did not differ between ARB and ACEI users (HR: 1.04; 95% confidence interval: 0.88 to 1.22). The findings were similar for new users of ACEI/ARB, and for those with preexisting heart failure.
Conclusions:
ARB users had the same 1-year mortality after myocardial infarction as ACEI users in routine care. Use of more costly ARB has increased dramatically over time, to a quarter of ACEI/ARB users, despite the lack of a therapeutic advantage for most patients.
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