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Review: ACE-Is or ARBs reduce adverse CV outcomes regardless of baseline systolic blood pressure.
MedLine Citation:
PMID:  22801699     Owner:  NLM     Status:  In-Data-Review    
QUESTION Do angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin-receptor blockers (ARBs) reduce adverse cardiovascular (CV) outcomes in normotensive patients with or at risk for atherosclerotic vascular disease? REVIEW SCOPE Included studies compared ACE-Is or ARBs given for ≥ 12 months with placebo in patients who had, or were at increased risk for, atherosclerotic vascular disease; enrolled ≥ 1000 patients; and prospectively assessed CV outcomes. Exclusion criteria were use of initial combination therapy or > 1 renin-angiotensin system modulator, and trials done exclusively in patients with hypertension. Outcomes were a composite of CV endpoints (first event of CV mortality, nonfatal myocardial infarction [MI], and nonfatal stroke), CV mortality, MI, stroke, and all-cause mortality. REVIEW METHODS MEDLINE, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials (all 1980 to Mar 2011); and reference lists were searched for randomized controlled trials (RCTs). Authors were contacted for data stratified by baseline systolic blood pressure (SBP). 13 RCTs (n = 80 594, mean age 55 to 70 y, 41% to 91% men, mean baseline SBP 113 to 152 mm Hg) met inclusion criteria; individual patient data were obtained for 10 RCTs and data stratified by baseline SBP for the other 3 RCTs. MAIN RESULTS Meta-analysis showed that ACE-Is or ARBs reduced the composite CV endpoint and its components more than placebo; ACE-Is or ARBs had a borderline statistical benefit for all-cause mortality (Table). Results were consistent across baseline SBP levels for the composite CV endpoint, all-cause mortality, MI, and stroke. ACE-Is or ARBs reduced CV mortality in patients with baseline SBP < 130 mm Hg (relative risk reduction [RRR] 16%, 95% CI 8 to 23) but not in those with higher baseline SBP (130 to 139 mm Hg, RRR 7%, CI -6 to 17; ≥ 140 mm Hg, RRR 0%, CI -7 to 7; P = 0.02 for interaction). CONCLUSIONS Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers reduce adverse cardiovascular outcomes in patients with, or at risk for, atherosclerosis. Results are consistent for most outcomes regardless of baseline systolic blood pressure.ACE-Is or ARBs vs placebo in patients with, or at increased risk for, atherosclerosis*OutcomesNumber of trials (n)Weighted event ratesRRR (95% CI)†NNT (CI)Composite CV endpoint‡13 (80 594)13% vs 14%10% (6 to 13)74 (54 to 116)All-cause mortality13 (80 594)10.9% vs 11.4%4% (0 to 8)Not significantCV mortality13 (80 594)6.8% vs 7.3%7% (2 to 11)211 (123 to 738)Fatal or nonfatal MI13 (72 576)3.8% vs 4.6%16% (11 to 22)133 (99 to 207)Fatal or nonfatal stroke13 (80 594)5.3% vs 5.8%9% (3 to 13)203 (130 to 610)*ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CV = cardiovascular; MI = myocardial infarction; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from odds ratios and control event rates reported in article using a fixed-effect model.†Interaction across baseline systolic blood pressure levels (< 130 mm Hg, 130 to 139 mm Hg, and ≥ 140 mm Hg) for CV mortality, P = 0.02; no interaction by systolic blood pressure level for other outcomes.‡First of CV mortality, nonfatal MI, or nonfatal stroke.
Vibhuti Singh
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Annals of internal medicine     Volume:  157     ISSN:  1539-3704     ISO Abbreviation:  Ann. Intern. Med.     Publication Date:  2012 Jul 
Date Detail:
Created Date:  2012-07-17     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0372351     Medline TA:  Ann Intern Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  JC1-8     Citation Subset:  AIM; IM    
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