Vibhuti Singh, MD, MPH
What are the benefits and harms of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II-receptor blockers (ARBs) in stable ischemic heart disease (IHD)?
Included studies compared ACE-Is or ARBs with placebo or active controls, or ACE-Is plus ARBs with either agent alone, in patients with stable IHD and preserved left ventricular (LV) function (e.g., mean ejection fraction [EF] > 0.40); included ≥ 75 patients; had ≥ 6-month follow-up; and reported ≥ 1 prespecified efficacy outcome (overall mortality, cardiovascular mortality, nonfatal myocardial infarction [MI], stroke, or a composite of the last 3 outcomes), or harms.
MEDLINE and EMBASE/Excerpta Medica (to Jul 2009), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (Issue 2, 2009), reference lists, and major cardiology meeting abstracts were searched for full reports of randomized controlled trials (RCTs), observational studies, or systematic reviews. 9 RCTs met the selection criteria: 7 (n = 32 559) used ACE-Is, 1 (n = 5926) used an ARB, and 1 (n = 25 620) used both ACE-Is and ARBs.
The main results are in the Table. In 1 RCT, ARBs did not reduce mortality or CV events more than placebo; benefits were borderline for the composite endpoint (relative risk reduction 12%, 95% CI 0 to 23). 1 RCT found that adding ARBs to ACE-Is increased discontinuations for adverse events; groups did not differ for mortality or CV outcomes.
In patients with stable ischemic heart disease and preserved ventricular function, good evidence exists for the effectiveness of ACE inhibitors; little evidence exists for ARBs.
ACE inhibitors vs placebo in patients with stable ischemic heart disease with preserved ventricular function*
*ACE = angiotensin-converting enzyme; AE = adverse event; CV = cardiovascular; MI = myocardial infarction; other abbreviations defined in Glossary. RRR, RRI, NNT, NNH, and CI calculated from data in article using a random-effects model.
Singh V. Good evidence supports use of ACE inhibitors in stable ischemic heart disease; little evidence exists for ARBs. Ann Intern Med. ;152:JC5–3. doi: 10.7326/0003-4819-152-10-201005180-02003
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Published: Ann Intern Med. 2010;152(10):JC5-3.
Cardiology, Coronary Heart Disease, Coronary Risk Factors, Hypertension, Nephrology.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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