Jason Bradfield, MD; Kalyanam Shivkumar, MD, PhD
In patients with an acute cardiovascular event, does early treatment with antihypertensive drugs reduce mortality?
Included studies compared an antihypertensive drug with placebo or no treatment in patients with an acute cardiovascular event, including myocardial infarction or stroke. Treatment was started within 24 hours of symptom onset and lasted ≤ 2 days (immediate treatment) or ≤ 10 days (short-term treatment). Outcomes were all-cause mortality at 2, 10, and ≥ 30 days.
MEDLINE and EMBASE/Excerpta Medica (to Feb 2009); Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, and Cochrane Database of Systematic Reviews; and references were searched for randomized controlled trials (RCTs) that followed patients for ≥ 24 hours and reported mortality at ≥ 1 of the specified time points. 65 RCTs (n = 166 206, mean age 61 y, 75% men) met the selection criteria. 40 trials were double-blind and placebo-controlled. 21 RCTs assessed immediate treatment, and 44 RCTs assessed short-term treatment. 4 classes of antihypertensive drugs were evaluated: nitrates (18 RCTs), angiotensin-converting enzyme (ACE) inhibitors (12 RCTs), β-blockers (20 RCTs), and calcium-channel blockers (CCBs, 18 RCTs). 59 trials enrolled patients with acute myocardial infarction, and 6 trials (all evaluating CCBs) enrolled patients with acute stroke.
Early treatment with nitrates reduced mortality at 2 and 10 days but not at ≥ 30 days (Table). ACE inhibitors reduced mortality at 10 days (Table) (no trial reported mortality for ≥ 30 d). Early treatment with β-blockers or CCBs did not affect mortality (Table). CCBs did not reduce 10-day mortality in patients with either acute myocardial infarction (risk ratio 1.57, 95% CI 0.87 to 2.83; 9 RCTs, n = 847) or acute stroke (risk ratio 0.81, CI 0.54 to 1.21; 5 RCTs, n = 1011).
In patients with an acute cardiovascular event, early treatment with nitrates or angiotensin-converting enzyme inhibitors reduces short-term mortality, but β-blockers and calcium-channel blockers do not affect mortality.
All-cause mortality after early treatment with antihypertensive drugs vs placebo or no treatment (control) in patients with acute cardiovascular events*
*ACE = angiotensin-converting enzyme; other abbreviations defined in Glossary. RRR, RRI, NNT, NNH, and CI calculated from data in article using a fixed-effect model.
Bradfield J, Shivkumar K. Review: Early treatment of a cardiovascular event with nitrates or ACE inhibitors reduces short-term mortality. Ann Intern Med. ;152:JC2–3. doi: 10.7326/0003-4819-152-4-201002160-02003
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Published: Ann Intern Med. 2010;152(4):JC2-3.
Cardiology, Coronary Risk Factors, Hypertension, Nephrology.
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