The Authors Reply We appreciate the constructive comments made by Dr. Imamura regarding our manuscript (1). First, we did not exclude patients with acute myocardial infarction (AMI) caused by vasospastic angina from our study population. The need for optimal medical therapy (OMT) for patients with AMI caused by vasospastic angina has not been established, partly because vasospastic angina is underdiagnosed, especially in Western countries (2). However, some patients with AMI caused by vasospastic angina might receive benefits from angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) or beta-blockers along with calcium-channel blockers, especially when the left ventricular systolic function is severely damaged by AMI. The inclusion of cases of AMI caused by vasospastic angina may facilitate future discussions concerning which types of OMT is necessary for patients with AMI caused by vasospastic angina.
Regarding the association between asthma and beta-blockers, the administration of β1 selective blockers should be considered in AMI patients with a reduced ejection fraction (3). Indeed, seven patients with asthma received beta-blockers, whereas five with asthma did not receive beta-blockers in our study population (Supplemental Table 3). However, more care should be taken when administering beta-blockers to patients with asthma than to patients without asthma, especially for AMI patients with a preserved ejection fraction. Therefore, the significant association between asthma and non-OMT was reasonable.
In the multivariate logistic regression analysis, we entered both hemodialysis and estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 without hemodialysis as independent variables, because there was a significant difference regarding the administration of ACE inhibitors/ARBs between patients with an eGFR <30 mL/min/1.73 m2 with hemodialysis and those without hemodialysis. Physicians might hesitate to administer ACE inhibitors/ARBs to patients with an eGFR <30 mL/min/1.73 m2 without hemodialysis but not to those with hemodialysis. Furthermore, our group reported poor clinical outcomes in AMI patients with an eGFR <30 mL/min/1.73 m2 without hemodialysis compared to those with hemodialysis (4).
Finally, we appreciate the great suggestion regarding the possibility of administering ivabradine for patients with hypotension. We agree with Dr. Imamura that ivabradine may expand the availability of OMT to patients with AMI.
Author's disclosure of potential Conflicts of Interest (COI).
Kenichi Sakakura: Advisary role, Boston Scientific and Abbott Vascular; Honoraria, Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline and NIPRO. Hideo Fujita: Advisary role, Mehergen Group Holdings.
References
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