ST elevation myocardial infarction inhibition of the renin-angiotensin-aldosterone system at discharge: Difference between revisions
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==Aldosterone Inhibition== | ==Aldosterone Inhibition== | ||
Data regarding the safety and efficacy [[aldosterone]] inhibition | Data regarding the safety and efficacy [[aldosterone]] inhibition is derived from trials of [[heart failure]] that enrolled patients with a prior [[MI]]. | ||
: '''RALES study (Randomized Aldactone Evaluation Study)''' | : '''RALES study (Randomized Aldactone Evaluation Study)''' | ||
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: In contrast to RALES, this study focused specifically on post-MI patients (n=6632). Despite co-administration of ACE inhibitors to these post-MI patients with either a ejection fraction < 40% or diabetes, eplerenone at a dose of 50 mg daily was associated with a significant reduction in all cause mortality, cardiovascular mortality, and cardiac hospitalizations <ref> Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.</ref> | : In contrast to RALES, this study focused specifically on post-MI patients (n=6632). Despite co-administration of ACE inhibitors to these post-MI patients with either a ejection fraction < 40% or diabetes, eplerenone at a dose of 50 mg daily was associated with a significant reduction in all cause mortality, cardiovascular mortality, and cardiac hospitalizations <ref> Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.</ref> | ||
While RALES and EPHESUS support the long-term administration of an aldosterone antagonists in post_MI patients with an EF < 40% or heart failure, the following are contraindications: | |||
* Creatinine > 2.5 mg/dl in men | |||
* Creatinine (Cr) > 2.0 mg/dl in women | |||
* Potassium (K+) > 5.0 mEq/L. | |||
* A relative contraindication is a creatinine clearance < 50 mL/min. | |||
==ACE vs Aldosterone Inhibition== | ==ACE vs Aldosterone Inhibition== | ||
Revision as of 01:29, 4 May 2009
| Myocardial infarction | |
| ICD-10 | I21-I22 |
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| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
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Angiotensin Converting Enzyme Inhibition
Aldosterone Inhibition
Data regarding the safety and efficacy aldosterone inhibition is derived from trials of heart failure that enrolled patients with a prior MI.
- RALES study (Randomized Aldactone Evaluation Study)
- Among patients with New York Heart Association class III to IV heart failure, treatment with spironolactone at an initial dose of 25 mg daily with an increase to 50 mg PO daily was associated with a 11% ARD (24% RRR) in all-cause mortality over 2 years despite co-administration of an ACE inhibitor in 95% of the patients. [1] In so far as 55% of the patients developed heart failure on the basis of ischemic heart disease, these results may be applicable to patients with STEMI.
- EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study)
- In contrast to RALES, this study focused specifically on post-MI patients (n=6632). Despite co-administration of ACE inhibitors to these post-MI patients with either a ejection fraction < 40% or diabetes, eplerenone at a dose of 50 mg daily was associated with a significant reduction in all cause mortality, cardiovascular mortality, and cardiac hospitalizations [2]
While RALES and EPHESUS support the long-term administration of an aldosterone antagonists in post_MI patients with an EF < 40% or heart failure, the following are contraindications:
- Creatinine > 2.5 mg/dl in men
- Creatinine (Cr) > 2.0 mg/dl in women
- Potassium (K+) > 5.0 mEq/L.
- A relative contraindication is a creatinine clearance < 50 mL/min.
ACE vs Aldosterone Inhibition
ACE inhibitors remain the first line of therapy given the large randomized trial data demonstrating their safety and efficacy following STEMI. Among STEMI patients with poor LV function who are intolerant to ACE inhibitors, Valsartan monotherapy at a dose 160 mg twice daily. Side effects and cost should be taken into consideration if a decision is made to administer Valsartan instead of an ACE inhibitor:
Guidelines (Do not edit)
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Class I 1. An ACE inhibitor should be administered orally during convalescence from STEMI in patients who tolerate this class of medication, and it should be continued over the long term. (Level of Evidence: A) 2. An ARB should be administered to STEMI patients who are intolerant of ACE inhibitors and have either clinical or radiological signs of heart failure or LVEF less than 0.40. Valsartan and candesartan have demonstrated efficacy for this recommendation. (Level of Evidence: B) 3. Long-term aldosterone blockade should be prescribed for post-STEMI patients without significant renal dysfunction (creatinine should be less than or equal to 2.5 mg/dL in men and less than or equal to 2.0 mg/dL in women) or hyperkalemia (potassium should be less than or equal to 5.0 mEq/L) who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF of less than or equal to 0.40, and have either symptomatic heart failure or diabetes. (Level of Evidence: A) Class IIa In STEMI patients who tolerate ACE inhibitors, an ARB can be useful as an alternative provided there are either clinical or radiological signs of heart failure or LVEF is less than 0.40. Valsartan and candesartan have established efficacy for this recommendation. (Level of Evidence: B)
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References
- ↑ Pitt B, Zannad F, Remme WJ, et al, for the Randomized Aldactone: Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709-17.
- ↑ Pitt B, Remme W, Zannad F, et al, for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-21.
Source