Paolisso P., et al,  Journal of the American Society of Echocardiography, Published: January 04, 2023DOI:https://doi.org/10.1016/j.echo.2022.12.022

Background

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown.

Objectives

To identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

Methods

Observational cohort study of 286 consecutive patients who underwent a standard echocardiographic assessment for suspected cardiac mass in Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of 6 echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numerical score, ranging from 0 to 6, with a cut-off of >3 balancing sensitivity and specificity with respect to the histological diagnosis of malignancy. Classification tree analysis (CTA) was used to determine the ability of echocardiographic parameters to discriminate sub-groups of patients with a differential risk of malignancy.

Results

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (p<0.001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (p<0.001). Infiltration, moderate-severe pericardial effusion, non-left localization, sessile, polylobate, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted count of >3 was very high (>0.90) and similar to that of the previously published weighted score. The CTA generated an algorithm in which infiltration was the best discriminator of malignancy, followed by non-left localization and sessile shape. The percentage correctly classified by the CTA as malignant was 87.5%. Agreement between observer readings and cardiac mass histology ranged between 85.1-91.5%. The presence of at least 3 echocardiographic parameters was associated with a lower survival.

Conclusions

In the approach to CM, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

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Ref:  Nishiura N., et al, J Am Heart Assoc. 2023;12:e025751. DOI: 10.1161/JAHA.122.025751

BACKGROUND: The natural history and optimal interventional timing in patients with isolated severe tricuspid regurgitation (TR) have not been well studied. This study aimed to investigate long-term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR.

Tricuspid regurgitation (TR) is a common echocardiographic finding, and it is encountered in 70% to 90% of the general population. TR has been believed to be a benign disease as it is often asymptomatic and can be managed conservatively with treatments such as diuretic therapy. However, it can sometimes cause right-sided heart failure and require surgical or catheter intervention. Recent studies demonstrated that increased TR severity was associated with higher mortality. Although surgical mortality can be adversely affected by delayed surgical intervention, the optimal timing of intervention for TR remains controversial. A recent study also reported that the prognosis of surgically treated moderate or greater TR did not differ significantly from that treated using medical therapy. Thus, the natural history and risk factors associated with poor outcomes in isolated severe TR remain understudied. Therefore, we aimed to determine the long-term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR to determine the optimal timing for intervention.

METHODS AND RESULTS: Consecutive transthoracic echocardiographic examinations in 2877 patients with isolated severe TR were retrospectively reviewed. Patients with significant left-sided valve disease or repeated examinations were excluded. Primary outcome was defined as a composite of all-cause death and hospitalization for heart failure. Among the 613 enrolled patients (mean age, 74±13 years; men, 38%), 141 died, and 62 were hospitalized for heart failure during the median follow-up period of 26.5 (interquartile range, 6.0–57.9) months. The 5-year event-free rate was 60.1%. TR pressure gradient (adjusted hazard ratio [HR], 1.03 [95% CI, 1.01–1.04]), blood urea nitrogen (adjusted HR, 1.02 [95% CI, 1.01–1.04]), left atrial volume index (adjusted HR, 1.01 [95% CI, 1.002–1.02]), and serum albumin (adjusted HR, 0.56 [95% CI, 0.36–0.95]) were identified as independent predictors of adverse events. A risk model based on the 4 clinical factors that included pulmonary hypertension (TR pressure gradient >40 mm Hg), elevated blood urea nitrogen levels (>25 mg/dL), decreased albumin levels (<3.7 g/dL), and left atrial enlargement (left atrial volume index <34 mL/m2) revealed a graded increase in the risk of adverse events (P<0.001).

CONCLUSIONS: The prognosis of isolated severe TR is not always favorable. Careful attention should be paid to patients with concomitant risk factors, such as pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement.

Diagram of association between advanced TR and multiorgan damages. LA indicates left atrial; LV, left ventricular; and TR, tricuspid regurgitation.

CLINICAL  PERSPECTIVE

What Is New?

• Patients with severe tricuspid regurgitation may experience adverse events in the long-term.
• A risk model based on pulmonary hypertension, renal and/or liver dysfunction, and left atrial enlargement showed a graded increase in the risk of future adverse events.

What Are the Clinical Implications?

• Intervention might be needed in patients with isolated severe tricuspid regurgitation with concomitant risk factors suspecting multiorgan damages.
• Additional studies are required to evaluate the influence of the interventions on clinical outcomes

in patients with severe tricuspid regurgitation with concomitant risk factors.

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Hospitalized patients with COVID-19 who have a history of chronic HF are at an increased risk for all-cause mortality, according to a study published in ESC Heart Failure.

“Advanced chronic HF (NYHA classes III and IV) is the strongest risk predictor of fatal outcome for COVID-19, and its negative impact on prognosis extends into the early post-hospitalization period, when COVID-19 patients with chronic HF feel worse than those without it, are more likely to seek unplanned medical care, and are more likely to develop de novo disease,” Gregory P. Arutyunov, MD, DSc, RAS, head of the department of internal diseases at Pirogov Russian National Research Medical University in Russia and colleagues wrote. “This suggests the need to develop optimal rehabilitation regimens and a multidisciplinary approach to the management of patients with chronic HF following COVID-19 infection.”

Hospitalized patients with COVID-19 who have a history of chronic HF are at an increased risk for all-cause mortality.

To observe the relationship between all-cause mortality rates and chronic HF history in patients hospitalized with COVID-19, Arutyunov and colleagues analyzed 5,616 patients aged 18 years or older (16.3% with chronic HF) hospitalized with COVID-19 in the Analysis of Comorbid Disease Dynamics in Patients with SARS-CoV-2 Infection (ACTIV) international registry. Patients were divided into two groups based on whether they had a history of chronic HF. All-cause mortality rates were collected in-hospital, as well as after 3 and 6 months of follow-up.

Researchers found that in-hospital mortality was higher in patients with a history of chronic HF than in those without a history of chronic HF (OR = 4.614; 95% CI, 3.633-5.859; P < .001). In-hospital all-cause mortality risk was higher in patients with more severe chronic HF, with patients in NYHA functional classes III and IV (OR vs. no chronic HF = 6.124; 95% CI, 4.538-8.266; P < .001) having higher risks than patients in functional classes I and II (OR vs. no chronic HF = 2.446; 95% CI, 1.831-3.267; P < .001). All-cause mortality risk was also higher in patients with ischemic chronic HF than in patients with nonischemic chronic HF (OR = 1.58; 95% CI, 1.05-2.45; P < .03). In addition, the increased all-cause mortality risk for patients with a history of chronic HF remained after 3 and 6 months of follow-up, according to researchers. “This detrimental interplay of chronic HF and COVID-19 requires careful monitoring, as there is a high likelihood of an increased burden of chronic HF and a change in the course of this condition due to COVID-19 infection,” Arutyunov and colleagues wrote. “Patients with chronic HF should be a priority group in national or population-wide vaccination programs.”

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cardiology today, 8^th Jan 2023 Adapted from: Tilly MJ, et al. Europace. 2022;doi:10.1093/europace/euac244

Autoimmune disorders were associated with elevated atrial fibrillation risk, particularly in women, according to a study published in EP Europace.

Using UK Biobank data from 2006 to 2022, 494,072 patients without AF (median age, 58 years; 55% women) were analyzed for rheumatic fever, gastrointestinal (GI) autoimmune diseases, autoimmune diseases of the musculoskeletal system and connective tissues, and neurological autoimmune diseases. After a median of 12.8 years, 5.5% of patients were diagnosed with new-onset AF.

“We found significant associations between new-onset AF and rheumatic fever without heart involvement, GI (Crohn’s disease and ulcerative colitis) and musculoskeletal system (rheumatoid arthritis, psoriatic and enteropathic arthropathies, polyarteritis nodosa, systemic lupus erythematosus and systemic sclerosis) autoimmune diseases, with AF incidence,” Martijn J Tilly, MS, of the department of epidemiology at Erasmus MC, University Medical Center Rotterdam, the Netherlands, and colleagues wrote. “Moreover, we found evidence of significant differences between men and women in these associations.”

The researchers found that patients had higher risk for developing AF if they had rheumatic fever without heart involvement (HR = 1.47; 95% CI, 1.26-1.72), Crohn’s disease (HR = 1.23; 95% CI, 1.05-1.45), ulcerative colitis (HR = 1.17; 95% CI, 1.06-1.31), rheumatoid arthritis (HR = 1.39; 95% CI, 1.28-1.51), polyarteritis nodosa (HR = 1.82; 95% CI, 1.04-3.09), systemic lupus erythematosus (HR = 1.82; 95% CI, 1.41-2.35) or systemic sclerosis (HR = 2.32; 95% CI, 1.57-3.44).

Autoimmune disorders were associated with elevated AF risk, particularly in women.

Women presented autoimmune disorders at higher rates than men for all but ulcerative colitis and ankylosing spondylitis. Rheumatic fever without heart involvement (HR = 1.79; 95% CI, 1.45-2.2), Crohn’s disease (HR = 1.35; 95% CI, 1.05-1.73), musculoskeletal system disorders (HR = 1.51; 95% CI, 1.38-1.66), rheumatoid arthritis (HR = 1.5; 95% CI, 1.35-1.67), psoriatic and enteropathic arthropathies (HR = 2.01; 95% CI, 1.32-3.05), systemic lupus erythematosus (HR = 1.79; 95% CI, 1.34-2.4), systemic sclerosis (HR = 2.51; 95% CI, 1.64-3.85), ankylosing spondylitis (HR = 1.53; 95% CI, 1.13-2.07) and multiple sclerosis (HR = 1.37; 95% CI, 1.07-1.75) were all significant associations for new-onset AF in women.

Although the incidence rate of new-onset AF in the total population was 4.49 per 1,000 person-years, the rate was 6.25 per 1,000 person years in men and 3.08 per 1,000 person-years in women. “Autoimmune diseases are significantly associated with the risk of new-onset AF in this prospective population-based study, comprising almost half a million participants,” Tilly and colleagues wrote. “Our findings further elaborate on and contribute to the current knowledge of the pathophysiological differences in autoimmunity between men and women.”

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Aaqib M., et al,  American Journal of Therapeutics 29(3):p e322-e333, May/June 2022. | DOI: 10.1097/MJT.0000000000000925.

Background: 

Sacubitril/valsartan (LCZ696) has progressed to be one of the most promising medication since its approval for chronic heart failure with reduced ejection fraction. Recent data have suggested a superior blood pressure control with LCZ696.

Data Sources: 

Randomized controlled trials (RCTs) comparing the efficacy and safety of LCZ696 against a placebo or angiotensin receptor blocker (ARB).

Study Design: 

We used a change in systolic and diastolic blood pressures, both sitting as well as ambulatory, to calculate relevant effect sizes with their standard errors from the available change in mean and SD data. In addition, we also collected categorical data for the reported adverse effects from these trials. We performed a series of pairwise meta-analyses between LCZ696 versus an active comparator or a placebo.

Results: 

Eleven RCTs with a total of 6028 participants had the relevant data available. Our meta-analysis showed that LCZ696 is an effective and a safe treatment for hypertension. It outperformed ARBs in every category, and the results are consistent across the different dosages of LCZ696. Compared with ARBs, 200 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure (DBP) by 4.62 mm Hg (95% confidence interval, 3.33–5.90, P < 0.001) and 2.13 mm Hg (95% confidence interval, 1.69–2.57, P < 0.001), respectively. Similarly, 400 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure by 5.50 mm Hg (2.94–8.07, P < 0.001) and 2.51 mm Hg (1.80–3.21, P < 0.001), respectively, in comparison with ARBs. The adverse effects with LCZ696 were not significantly higher compared with ARBs or placebo.

Conclusions: 

Sacubitril/valsartan is more effective for the management of hypertensive patients, compared with an ARB. Long-term prospective studies are required to identify whether this result translates into morbidity and mortality benefits.

The post Efficacy of Sacubitril/Valsartan in Hypertension first appeared on Serene.

1.Carvalho P. et al, Clinical Research in Cardiology, Received: 22 September 2022 / Accepted: 21 December 2022 , Published online 2 Jan 2023, https://doi.org/10.1007/s00392-022-02148-2

2. Braunwald E., SGLT2 inhibitors: the statins of the 21st century, European Heart Journal (2022) 43, 1029–1030, https://doi.org/10.1093/eurheartj/ehab765

Background We sought to compare cardiovascular outcomes, renal function, and diuresis in patients receiving standard diuretic therapy for acute heart failure (AHF) with or without the addition of SGLT2i.

Acute heart failure (AHF) is the leading cause of unplanned hospitalization in those over 65 years and is characterized by new-onset or worsening symptoms of heart failure (HF). Most patients with AHF are admitted with evidence of fluid overload and are generally treated with escalating doses of intravenous loop diuretics to improve symptoms and reduce morbidity. However, this diuretic regimen is limited by worsening renal function and many patients do not obtain adequate decongestion during the hospital stay for AHF. In fact, current treatment for AHF has not changed significantly in decades. Unsurprisingly, post discharge outcomes have remained poor with 30-day readmission and 1-year mortality rates being as high as 20–30%. Therefore, there is an unmet need for new therapeutic strategies in this population.

In recent years, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been proved to be effective in the treatment of HF for reducing cardiovascular mortality and hospitalizations, regardless of diabetes or ejection fraction status. SGLT2i also reduce the composite outcome of cardiovascular death or deterioration of renal function in patients with chronic kidney disease (CKD). However, less is known about the safety and efficacy of adding SGLT2i to conventional diuretic therapy in patients admitted with AHF.

A prior meta-analysis examining this issue found a reduction in rehospitalizations for HF in patients treated with SGLT2i. However, there was no significant decrease in mortality with SGLT2i, which may have been related to limited power . Therefore, we aimed to perform an updated systematic review and meta-analysis of randomized controlled trials (RCTs) comparing conventional diuretic therapy with or without concomitant SGLT2i for cardiovascular and renal endpoints in patients with AHF.

Methods and results

Systematic search of three electronic databases identified nine eligible randomized controlled trials involving 2,824 patients. The addition of SGLT2i to conventional therapy for AHF reduced all-cause death (odds ratio [OR] 0.75; 95% CI 0.56–0.99; p = 0.049), readmissions for heart failure (HF) (OR 0.54; 95% CI 0.44–0.66; p < 0.001), and the composite of cardiovascular death and readmissions for HF (hazard ratio 0.71; 95% CI 0.60–0.84; p < 0.001). Furthermore, SGLT2i increased mean daily urinary output in liters (mean difference [MD] 0.45; 95% CI 0.03–0.87; p = 0.035) and decreased mean daily doses of loop diuretics in mg of furosemide equivalent (MD -34.90; 95% CI [− 52.58, − 17.21]; p < 0.001) without increasing the incidence worsening renal function (OR 0.75; 95% CI 0.43–1.29; p = 0.290).

Conclusion

SGLT2i addition to conventional diuretic therapy reduced all-cause death, readmissions for HF, and the composite of cardiovascular death or readmissions for HF. Moreover, SGLT2i was associated with a higher volume of diuresis with a lower dose of loop diuretics.

Some Facts about SGLT2i ²

• Between 2012 and 2015, the European Medicine Agency (EMA) and the US Food and Drug Administration (FDA) approved three SGLT2is, dapagliflozin, canagliflozin, and empagliflozin, for reducing plasma glucose in persons with T2DM
• SGLT2i are not only glucosuric but also reduce the development and progression of heart failure and prolong life in patients with T2DM and reduced left ventricular ejection fraction
• SGLT2i improve outcomes in patients with HFrEF irrespective of the presence or absence of T2DM, thereby greatly expanding the potential target population for these drugs.
• SGLT2i appear to be beneficial in patients with chronic heart failure over a wide range of ejection fractions, again greatly expanding the target population even further.
• SGLT2i slow the development of end-stage kidney disease in patients with chronic kidney disease. The benefit of SGLT2i in patients without T2DM but with a variety of chronic kidney diseases is under investigation.

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Daniel Vari etal., Pediatric Cardiology (2022) on Published: 22 October 2022

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants. Once diagnosed, infants are admitted for antiarrhythmic therapy and discharged after observation. There are limited data on risk factors for readmission and readmission rates, while on medication.

The objective of this study was to investigate risk factors for readmission and outcomes in infants diagnosed with SVT. This is a single-center retrospective study over a 10-year period of infants under 6 months of age with documented SVT. Infants with congenital heart disease requiring surgical or catheter intervention, gestational age less than 32 weeks or diagnosis of atrial flutter or fibrillation were excluded. The primary outcome was readmission within 31 days of hospital discharge. Long term need for ablation and eventual discontinuation of medications were assessed. Ninety patients were included. Beta blockers were the initial therapy in 66 and 28 required a medication change. Nineteen were readmitted within 31 days of discharge. The only clinical factor associated with early readmission was presence of ventricular pre-excitation (6/19 vs. 8/71, p = 0.03). Patients who were readmitted within 31 days had a longer length of treatment (12 [11.5, 22.0] vs. 10 [7.5, 12.0] months, p = 0.007) and were more likely to undergo ablation (4/19 vs. 2/71, p = 0.017). In this cohort of infants with SVT, readmission was common and ventricular pre-excitation was identified as a risk factor for readmission.

 Infants who were readmitted within 31 days of discharge had longer length of antiarrhythmic therapy and were more likely to undergo catheter ablation.

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Gechu Shang etal., Heart and Vessels (2022), Published on 01 November 2022

Blood potassium levels are associated with adverse outcomes in patients with congestive heart failure (HF). However, it is unclear whether there are differences in outcome events in elderly patients with different blood potassium levels at the time of emergency readmission within 1 year. This study used data from patients hospitalized with HF, integrating electronic medical records from the PhysioNet restricted health data database and external outcome data. We conducted a retrospective study of HF patients aged 60 years and older, using baseline data, comorbidities, laboratory tests, and medication use as covariates to analyze the effect of serum potassium levels on outcome events, with the primary outcome being readmission within 1 year. A priori was used to calculate the sample size, and this retrospective cohort study included a total of 788 elderly HF patients, of whom 20.3% had hypokalaemia (K⁺  < 3.5 mmol/L) and 14.7% had hyperkalemia (K⁺  > 4.7 mmol/L). According to a multivariate Cox regression model, patients with hyperkalemia had a shorter time interval between readmissions within 1 year, with a hazard ratio (HR) and its 95% CI of 1.134 (1.006–1.279). Three models were used to analyze patients with different blood potassium levels and, after correction, the high potassium group was at high risk relative to the low and normal groups, with significant differences in outcome events, with HRs and their 95% CI of 1.266 (1.03–1.557), 1.245 (1.01–1.534), and 1.439 (1.142–1.812), respectively. The robustness of the model was also demonstrated by competing risk models with subgroup analysis, showing that blood potassium levels had a stable effect on outcome events and were not altered by covariates (age, sex, diabetes, chronic kidney disease, NT-proBNP, high-sensitivity troponin, and glomerular filtration rate).

The results show that high blood potassium levels are associated with the outcome event of readmission within 1 year in elderly patients with HF. Blood potassium levels at the time of the first hospitalization may therefore be a valuable predictor.

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Ref: Satit Janwanishstaporn, JACC Heart Fail. 2022 Jan;10(1):27-37.  doi: 10.1016/j.jchf.2021.08.007. Epub 2021 Nov 10.

Introduction

Patients with reduced ejection fraction (EF) often show improvement in left ventricular EF (LVEF). Patients having LVEF increases by an absolute amount of 10% or ≥40% from a baseline <40% are referred to as having heart failure with improved EF (HFimpEF). Patients with HFimpEF have a variable clinical course. Global longitudinal strain (GLS), a sensitive indicator of LV systolic function, may be a valuable predictor of risk of future events in this patient subgroup.

Aim

To determine whether GLS would independently predict future clinical events in patients with HFimpEF

Assessment

• GLS was assessed using 2-dimensional speckle-tracking software on index echocardiography

Results

• The median age of the study population was 64 years, 70% were male, 68.5% had nonischemic etiology, and 75.9% had New York Heart Association (NYHA) functional class I or II symptoms.
• Median time from first HF diagnosis to index echocardiography was 22 months, median absolute values of GLS (aGLS) and LVEF from index echocardiography were 12.7% and 52%, respectively.
• The incidence of primary outcome, over the period of 53 months following index echocardiography, was less frequent in patients with aGLS above the median than below it (Fig. 1).
• Assessment as a continuous variable revealed that each 1% increase in aGLS on index echocardiogram was associated with a lower likelihood of the composite outcome (HR; 0.86, 95% CI; 0.79-0.93, P <0.001). The association persisted after multivariable adjustment as well (HR; 0.90, 95% CI; 0.82-0.97, P=0.01).
• LVEF reduction >5% to <40% was observed in 88 (38.6%) patients. Lower aGLS was associated with increased likelihood of deteriorating LVEF, thus; deterioration in LVEF was more common in patients with aGLS below the median vs.  those with aGLS above the median (49.6% vs. 25.7%, P <0.001).
• Patients with LVEF below the median at the index echocardiography had higher rate of VT or appropriate ICD shock (6.4% vs. 1.9%; P=0.047) during subsequent follow-up.

Conclusions

• Patients with HFimpEF had a better prognosis as compared with patients having persistently low LVEF. Such patients were at a low risk of worsening HF, CV death and future deterioration of cardiac function.
• GLS was a strong and independent predictor for future HF events and deteriorating cardiac function in patients with HFimpEF.
• It is therefore important to look for deterioration in patients with impaired GLS, despite having normalized LVEF.

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Several clinical trials have demonstrated the superiority of angiotensin receptor-neprilysin inhibitor (ARNI) over angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in patients with heart failure with reduced ejection fraction (HFrEF). Nevertheless, there is a dearth of evidence with respect to the long-term benefits of ARNI over ACEI or ARB among patients with acute myocardial infarction (AMI).

Aim

This study aimed to compare the efficacy of angiotensin receptor-neprilysin inhibitor (ARNI) therapy with angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) therapy for cardiovascular outcomes in patients with acute myocardial infarction (AMI).

Outcomes

Primary Outcome

• Incidence of the composite outcome including CV death, MI, HF hospitalization, and ischemic stroke

Secondary Outcomes

• CV death
• Rehospitalization for worsening HF
• Occurrence of MI and stroke

Follow-up

• 24 months

Results

• The mean duration of follow-up was 9.35, 8.63, and 9.21 months for the patients treated with ARNI, ACEI and ARB, respectively. The mean ages were 61.82, 61.98, and 62.13 years among patients treated with ARNI, ACEI, and ARB, respectively.

• Patients treated with ARNI had a significant 49% and 53% lower incidence of the composite CV outcome than ACEI , and ARB users (HR; 0.47, 95% CI; 0.24–0.90, P=0.02], respectively (Fig. 1).  

• Patients treated withs ARNI had a significant 63% and 59% lower incidence of CV death than ACEI (HR; 0.37, 95% CI; 0.18–0.79, P=0.01) and ARB users (HR; 0.41, 95% CI; 0.18–0.95, P=0.04], respectively.
• As per a subgroup analysis, patients with LVEF ≤40% were benefitted more from ARNI, compared with ACEI [HR; 0.30, 95% CI; 0.11–0.86, P=0.01) or ARB (HR; 0.21, 95% CI; 0.04–1.1, P=0.05).
• Patients aged ≤60 years exhibited reduced incidence of composite outcomes (HR for ARNI vs. ARB; 0.11, 95% CI; 0.03–0.46, P=0.002).

Conclusions

• Amongst patients with AMI, ARNI was superior to ACEI/ARB in terms of reducing the long-term adverse CV outcomes.
• Subgroup analysis further revealed that ARNI was more likely to benefit patients with LVEF less than 40% and aged less than 60 years.

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