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Angiotensin-converting enzyme inhibitor (ACEI) was the first clinically approved renin-angiotensin-aldosterone system (RAS) inhibitor, and much evidence presented in the 1990s and early 2000s have demonstrated the effectiveness of ACEI for improving cardiovascular disease-related morbidity and mortality.1-5 Angiotensin II receptor blocker (ARB) has also been examined clinically for cardiovascular disease treatment.6-10 Based on the results of 2 randomized clinical trials (RCTs) such as Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan (OPTIMAAL) and the Valsartan in Acute Myocardial Infarction (VALIANT), which examined clinical impacts of ARB after acute myocardial infarction (AMI), the international guidelines recommend that ACEI should be used as the first-line treatment after AMI and that ARB should be considered in patients who are intolerant to ACEI therapy.6,7,11,12 We investigated whether ACEI and ARB had comparable long-term benefits in a large cohort of post-AMI patients registered in the Osaka Acute Coronary Insufficiency Study (OACIS).13,14
Methods
The OACIS is a prospective, multicenter, observational study enrolling consecutive patients with AMI at 25 collaborating hospitals in the Osaka region of Japan.13,14 The OACIS is registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) in Japan (ID: UMIN000004575). Details of OACIS are described elsewhere (Supplementary Material ).13,14
The diagnosis of AMI was based on the World Health Organization criteria,15 which required 2 of the following 3 criteria to be met: (1) clinical history of central chest pressure, pain, or tightness lasting >=30 minutes; (2) ST-segment elevation >0.1 mV in at least 1 standard or 2 precordial leads; and (3) an increase in serum creatine phosphokinase concentration of more than twice the normal laboratory value. Research cardiologists and trained research nurses recorded data concerning sociodemographic variables, medical history, therapeutic procedures, and clinical events during the patient's hospital stay. The present study protocol complied with the Declaration of Helsinki and was approved by the institutional ethical committee of each participating institution. All study candidates were informed about data collection and blood sampling, and written informed consents were obtained.
A flowchart of patient selection is presented in Supplementary Figure 1 . A total of 4,425 patients treated with ACEI at discharge, 2,158 with ARB, and 2,442 prescribed neither ACEI nor ARB (no RAS inhibitor) were enrolled in...