Comparative Effectiveness of Sacubitril-Valsartan versus ACEI/ARB in Patients with Acute Myocardial Infarction and Heart Failure with Reduced Ejection Fraction: A Prospective Study from Bangladesh

Abstract

Background: Acute myocardial infarction (AMI) complicated by heart failure with reduced ejection fraction (HFrEF) creates notable therapeutic obstacles. Although Sacubitril-Valsartan (ARNI) has shown effectiveness in chronic HFrEF, especially in resource-constrained areas its relative efficacy against ACEI/ARB treatment in the post-AMI environment stays under-researched. Objective: To assess the clinical results, safety profile, and cost-effectiveness of Sacubitril-Valsartan against ACEI/ARB in AMI patients with HFrEF. Methods: Two hundred AMI patients with HFrEF (LVEF <40%) were randomly assigned to either Sacubitril-Valsartan (n=100) or ACEI/ARB (n=100) in this tertiary centre in Bangladesh as part of a randomized controlled trial, conducted from July 2023 to June 2024 at BSMMU. Over six months, primary endpoints were LVEF change, NT-proBNP drop, hospitalization, and death rates. Secondary results included KCCQ-based quality of life, negative events, and cost study. Results: The Sacubitril-Valsartan group showed better results: more LVEF improvement (8.4±3.2% vs 4.1±2.9%, p=0.001), more pronounced NT-proBNP reduction (65% vs 35%, p=0.001), lower hospitalization (8% vs 18%, p=0.01), and lower mortality (5% vs 12%, p=0.03). Improvements in quality of life were much better with ARNI (25-point vs 13-point KCCQ rise, p=0.001). While other negative events were similar, ARNI raised hyperkalemia incidence (6% vs 3%, p=0.04). Though more expensive (1500±200 USD vs 800±150 USD, p=0.04), ARNI's clinical advantages were significant. Conclusion: Although it is more expensive, sacubitril-valsartan demonstrates better effectiveness than ACEI/ARB in improving cardiac function, reducing adverse effects, and enhancing post-AMI HFrEF quality of life. This is particularly notable in South Asian populations, emphasising the need for attention to therapeutic guidelines for AMI-related HFrEF.