Objective:

To evaluate the effects of early in-hospital initiation of ARNI therapy compared with ACE inhibitor or ARB therapy on cardiovascular outcomes in post-AMI patients with impaired systolic function.

Approach:

• Study Design: Systematic review and meta-analysis of randomized controlled trials (RCTs) enrolling hospitalized AMI patients with impaired systolic function (LVEF <50%).
• Primary Outcome: Major adverse cardiovascular events (MACEs), including HF hospitalization, all-cause mortality, or recurrent acute coronary syndrome.
• Secondary Outcomes: Incidence of ventricular arrhythmia, cardiovascular death, stroke, changes in LVEF, NT-proBNP levels, and adverse events.

Key Findings:

• Early in-hospital ARNI initiation significantly reduced MACEs (RR 0.58; 95% CI 0.41–0.83; NNT ≈ 7).
• ARNI therapy reduced the incidence of ventricular arrhythmia (RR 0.51; 95% CI 0.35–0.75; NNT ≈ 25).
• ARNI improved LVEF (mean difference +2.54%; 95% CI +1.34 to +3.75) and reduced NT-proBNP levels (mean difference −424 pg/mL; 95% CI −779 to −68).
• ARNI was associated with higher rates of adverse events (RR 1.16; 95% CI 1.14–1.19), primarily symptomatic hypotension (RR 1.32; 95% CI 1.20–1.46).

Interpretation:

Early in-hospital initiation of ARNI reduces MACEs and improves ventricular function in post-AMI patients with impaired left ventricular systolic function, though monitoring for hypotension is necessary.

Limitations:

• The study included only RCTs, which may limit generalizability.
• The follow-up duration was approximately 6 months, necessitating longer-term outcome studies.

Conclusion:

Early in-hospital ARNI adoption in high-risk post-AMI patients is supported.