From the Guidelines
The 4-pillar therapy approach, including ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and diuretics, is beneficial in managing STEMI-induced acute heart failure, as it reduces the risk of hospitalization and death, and improves symptoms. This approach is supported by the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1. The guidelines recommend ACE inhibitor (or ARB) therapy as soon as haemodynamically stable for all patients with evidence of LVEF <40% and/or heart failure to reduce the risk of hospitalization and death, with a Class I, Level A recommendation.
- Beta-blocker therapy is also recommended in patients with LVEF <40% and/or heart failure after stabilization, to reduce the risk of death, recurrent MI, and hospitalization for heart failure, with a Class I, Level A recommendation 1.
- An MRA is recommended in patients with heart failure and LVEF <40% with no severe renal failure or hyperkalaemia to reduce the risk of cardiovascular hospitalization and death, with a Class I, Level B recommendation 1.
- Loop diuretics are recommended in patients with acute heart failure with symptoms/signs of fluid overload to improve symptoms, with a Class I, Level C recommendation 1. The use of these therapies in combination can help to improve outcomes in patients with STEMI-induced acute heart failure, by reducing morbidity and mortality, and improving quality of life.
From the Research
Benefits of 4 Pillar Therapy in STEMI Induced Acute Heart Failure
- The concept of 4 pillar therapy typically includes angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin receptor-neprilysin inhibitors (ARNI), and other medications such as diuretics or mineralocorticoid receptor antagonists, tailored to individual patient needs.
- According to the study 2, ACE inhibitors have been shown to significantly decrease the risk for cardiovascular events in both STEMI and NSTEMI patients, which suggests a potential benefit of 4 pillar therapy in STEMI induced acute heart failure.
- The study 2 also found that sacubitril/valsartan, an ARNI, did not significantly decrease the risk for cardiovascular death and HF in patients with AMI complicated by left ventricular dysfunction, irrespective of the type of AMI, which may indicate that the benefits of 4 pillar therapy may not be entirely due to the ARNI component.
- Another study 3 highlights the importance of combining beta-blockers and ACE inhibitors in managing various cardiovascular diseases, including heart failure, which supports the idea that a multi-faceted approach like 4 pillar therapy could be beneficial in STEMI induced acute heart failure.
Mechanisms and Rationale
- The combination of beta-blockers and ACE inhibitors, as discussed in 3, provides complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system, which are crucial in managing heart failure and reducing cardiovascular risk.
- The use of ACE inhibitors, beta-blockers, and other components of 4 pillar therapy may help to address the complex pathophysiology of STEMI induced acute heart failure, including reducing afterload, decreasing remodeling, and improving cardiac function.
- However, the optimal combination and dosing of these medications, as well as the potential benefits and limitations of 4 pillar therapy in STEMI induced acute heart failure, require further investigation and consideration of individual patient characteristics and needs.