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ACE inhibitors plus standard medical therapy linked with reduced risk for mortality
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The use of ACE inhibitors was associated with a reduction in mortality risk, MI and stroke in patients with ischemic heart disease when compared with both angiotensin II receptor antagonists and placebo.
Researchers examined data from 37,148 participants enrolled in eight clinical trials. Trials included in the systematic review were of at least six months duration and were conducted to compare either ACE inhibitors, AII receptor antagonists or their combination vs. placebo or active control in patients with stable IHD and preserved left ventricular function. The studies were screened by two independent investigators.
The researchers reported that ACE inhibitors were associated with a reduced risk for total mortality (RR=0.87; 95% CI, 0.81-0.94) vs. placebo. Results from one of the eight selected clinical trials suggested that AII receptor antagonists did not affect the risk for total mortality in patients resistant to ACE inhibitors vs. placebo (RR=1.05; 95% CI, 0.91-1.20). Results from a pooled analysis suggested that ACE inhibitors reduced the risk for CV mortality vs. placebo (RR=0.83; 95% CI, 0.70-0.98).
The researchers also reported that ACE inhibitors were associated with reduced risk for nonfatal MI (RR=0.83; 95% CI, 0.73-0.94) and stroke (RR=0.78; 95% CI, 0.63-0.97) vs. placebo. Patients assigned ACE inhibitors were also more likely to withdraw from therapy due to adverse events than those assigned placebo (RR=2.30; 95% CI, 1.34-3.95). The researchers also reported that AII receptor antagonists were associated with reduced risk for total mortality (RR=1.07; 95% CI, 0.98-1.16) and MI (RR=1.08; 95% CI, 0.94-1.23) but were also associated with an increased risk for discontinuation due to syncope (P=.035) and hypotension (P<.001) in combination with ACE inhibitors vs. ACE inhibitors alone.
“Adding an ACE inhibitor to standard medical therapy improves clinical outcomes in some patients with stable ischemic heart disease and preserved LV function,” the researchers concluded. “Combination therapy seems no better than ACE inhibitor therapy alone and increases harms. Future trials are needed to more clearly define the role of [AII receptor antagonists] in this population.”
Baker WL. Ann Intern Med. 2009;PMID:19843530.