Effect of angiotensin receptor neprilysin inhibitors in patients with STEMI: a systematic review and meta-analysis

ST-segment elevation myocardial infarction (STEMI) is responsible for high morbidity and mortality rates globally. Although the use of angiotensin-converting enzyme inhibitors (ACEIs) remains the cornerstone treatment for patients with STEMI, the use of angiotensin-receptor neprilysin inhibitors (ARNIs) may offer better outcomes than ACEIs. This meta-analysis compares the efficacy and safety of ARNIs versus ACEIs in patients with STEMI. Randomized controlled trials (RCTs) were pooled from PubMed and Cochrane databases. A random-effects model calculated risk ratios (RRs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs). Five trials (<i>n</i> = 4,915) were included. ARNIs significantly reduced major adverse cardiovascular events (MACE) (RR: 0.66, 95% CI [0.50, 0.86]; <i>p</i> = 0.002) and hospitalizations for heart failure (HHF) (RR: 0.67, 95% CI [0.49, 0.92]; <i>p</i> = 0.01). ARNIs also improved left ventricular ejection fraction (LVEF) (WMD: 2.60, 95% CI[1.53, 3.68]; <i>p</i> &lt; 0.00001) and lowered NT-proBNP levels (WMD: −268.89, 95% CI[−422.35, −115.42]; <i>p</i> = 0.0006). No significant differences were observed in recurrent myocardial infarction, cardiovascular death, or safety outcomes – except for hypotension, which was significantly more common with ARNI use. ARNI therapy reduces MACE, HHF, and NT-proBNP levels and improves LVEF in patients with STEMI without increasing safety risks, except for hypotension. Further RCTs are needed to confirm these findings. ST-elevation myocardial infarction (STEMI) is a serious type of heart attack that continues to cause major health problems worldwide. After a STEMI, medications such as angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed to support heart recovery and prevent further complications. In this study, we compared the effectiveness and safety of ACEIs with a newer class of medications called angiotensin receptor neprilysin inhibitors (ARNIs) in over 4,900 patients who had experienced a STEMI. Our findings showed that patients treated with ARNIs had a lower risk of serious heart complications and were less likely to be hospitalized for heart failure. Additionally, those receiving ARNIs experienced greater improvement in heart function compared to those on ACEIs. Importantly, the overall safety of ARNIs was similar to that of ACEIs, with no significant increase in side effects. These results suggest that ARNIs may offer meaningful benefits for patients recovering from a STEMI and could be considered as an alternative to traditional ACEI therapy.