Abstract
We thank Dr Kostis for his interest in our study and agree that several important limitations need to be considered before interpreting our study. 1 We analyzed acute myocardial infarction (AMI) patient data from the Korea Acute Myocardial Infarction Registry–National Institutes of Health registry to see whether there is any survival difference between patients with AMI treated with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II type 1 receptor blockers (ARBs). However, significant proportions of patients treated with ACEIs did not maintain the drugs at 12 months and additional proportions of ACEI-treated patients switched to ARBs during the follow-up period, which was not systematically assessed. Thus, exact maintenance period of specific drugs and their specific adverse effects could not be analyzed, although maintenance rate of statin was higher than 90% at 12 months. Despite these limitations, benefits of ACEI versus ARB with respect to mortality were already evident at 6 months after survival discharge. 1
We also agree that we could not separate the blood pressure (BP)-dependent effects from BP-independent effects of the ACEIs and ARBs. As Dr Kostis JB addressed in the letter, analyses by the Blood Pressure Lowering Treatment Trialists’ Collaboration have shown that ACEIs have additional BP-independent beneficial effects on coronary heart disease (nonfatal myocardial infarction or death from CHD), whereas no such effect was observed for ARB. 2 In our study, we have focused on mortality, because several studies including randomized controlled trials and meta-analyses have shown that ACEIs provide a better survival benefit than ARBs in patients with various cardiovascular (CV) risks. 3 -5 Although we did not present individual CV outcomes in a detailed manner, we did observe that adjusted hazard ratio for a composite outcome composed of nonfatal myocardial infarction, nonfatal stroke, and CV death was also lower in the ACEI group compared to the ARB group, as described briefly. 2 Thus, our study suggested that such BP-independent effects of ACEIs may have some clinical implications for the management of AMI.
We hope that our findings reflecting current real-world AMI management will provide a new perspective in the study of the differences between the 2 agents.
