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RAS inhibitors not more effective than other drugs in stable CAD
There is not enough evidence to support using renin-angiotensin system inhibitors as a preferred treatment over other agents in patients with CAD without HF, according to findings from a meta-analysis.
“In patients with stable [CAD] without [HF], [renin-angiotensin system inhibitors] reduced [CV] events and death only when compared with placebo but not when compared with active controls. Even among placebo-controlled trials in this study, the benefit of [renin-angiotensin system inhibitors] was mainly seen in trials with higher control event rates but not in those with lower control event rates,” Sripal Bangalore, MD, MHA, associate professor, department of medicine, Leon H. Charney Division of Cardiology, NYU Langone Medical Center, and colleagues wrote.
Bangalore, a member of the Cardiology Today Editorial Board, and colleagues conducted a meta-analysis of 24 randomized trials that included searches of PubMed, EMBASE and CENTRAL databases from inception through May 1, 2016.
All the trials were randomized trials evaluating renin-angiotensin system (RAS) inhibitors vs. placebo or active controls. All trials included at least 100 patients with at least 1 year of follow-up. All patients had stable CAD without HF, defined as having left ventricular ejection fraction 40% or having no presence of clinical HF. The researchers did not include studies with redacted or compared use of ACE inhibitors with angiotensin receptor blockers.
The following outcomes were evaluated: death, CV death, MI, angina, stroke, HF, revascularization, incident diabetes and drug withdrawal due to adverse effects.
Reduced risks were found with the use of RAS inhibitors vs. placebo: all-cause mortality (RR = 0.84, 95% CI, 0.72-0.98); CV mortality (RR = 0.74; 95% CI, 0.59-0.94); MI (RR = 0.82; 95% CI, 0.76-0.88); stroke (RR = 0.79; 95% CI, 0.7-0.89); angina (RR = 0.94; 95% CI, 0.89-0.99); HF (RR = 0.78; 95% CI, 0.71-0.86); and revascularization (RR = 0.93; 95% CI, 0.89-0.98).
However, in trials comparing RAS inhibitors with other active controls, the RAS inhibitors failed to show similar benefits. RAS inhibitors did not decrease risk when compared with active controls for the following: all-cause mortality (RR = 1.05; 95% CI, 0.94-1.17; P for interaction = .006); CV mortality (RR = 1.08; 95% CI, 0.93-1.25; P for interaction < .001); MI (RR = 0.99; 95% CI, 0.87-1.12; P for interaction = .01); and stroke (RR = 1.1; 95% CI, 0.93-1.31; P for interaction = .002).
“Even among the placebo-controlled trials, the benefit of RAS [inhibitors] was only seen in trials with high baseline risk and not in those with low baseline risk. Therefore, the blanket recommendation to use RAS [inhibitors] for all patients with [CAD] is not supported by evidence,” Bangalore and colleagues wrote. – by Suzanne Reist
Disclosure: Bangalore reports receiving honoraria from Abbott, Abbott Vascular, Boehringer Ingelheim, Daiichi Sankyo, Gilead, Merck and Pfizer. Please see the full study for a list of the other researchers’ relevant financial disclosures.