Personalizing Renin-angiotensin System Blockade at Discharge in ST-elevation Myocardial Infarction Following Percutaneous Coronary Intervention: Prognostic Utility of the GRACE Score

초록

BACKGROUND Renin-angiotensin system inhibitors (RASi) improve outcomes after myocardial infarction (MI) in patients with left-ventricular dysfunction or clinical heart failure, but the benefit in contemporary ST-segment elevation MI (STEMI) treated with drugeluting stents (DES) may depend on baseline risk. Whether the Global Registry of Acute Coronary Events (GRACE) score can guide RASi use at discharge is uncertain. METHODS We conducted a post-hoc analysis of the nationwide Korea Acute MI registry-National Institute of Health (KAMIR-NIH) registry (2011–2015). Patients with STEMI who treated with DES and were discharged alive were included; those with failed PCI, bare-metal stents, non-ST-elevation MI (NSTEMI), in-hospital death, or key missing data were excluded. Patients were categorized by prespecified GRACE strata (≤100 vs. >100). The exposure was discharge RASi [angiotensin converting enzyme inhibitor (ACEI) or angiotensinreceptor blocker (ARB)]. The primary endpoint was all-cause death at 3 years; secondary endpoints included cardiac death and nonfatal events at 6, 12, and 36 months. Cox models (unadjusted and GRACEadjusted) and 1:1 propensity-score matching (within strata) were used. GRACE discrimination for 6- and 12-month mortality was assessed by receive operating characteristics (ROC) analysis. RESULTS Of 5261 patients, 4299 (81.8%) received RASi at discharge. GRACE discriminated short-term mortality; the empirical Youden region was ∼125, and 100 was used for risk stratification. In GRACE ≤100 (n=2387), event rates were low and similar with versus without RASi (death 1.2% vs 1.8% at 36 months). In GRACE >100 (n=2874), RASi was associated with lower death at 6, 12, and 36 months (2.1% vs 5.0%; 3.5% vs 6.6%; 8.2% vs 12.8%; all P≤0.001) and lower cardiac death; 36-month major adverse cardiac events (MACE) was also reduced (17.1% vs 21.7%; P=0.011). GRACE-adjusted Cox and propensity-matched analyses (335/ 335 and 500/500 pairs) were consistent. CONCLUSION After successful PCI for STEMI, GRACE-guided discharge prescribing identifies patients most likely to benefit from RASi. RASi should be prioritized for GRACE >100, while individualized decision-making is reasonable for GRACE ≤100 absent other standard indications.