Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin-Receptor Blockers (ARBs) in Patients at High Risk of Cardiovascular Events: A Meta-Analysis of 10 Randomised Placebo-Controlled Trials
Context. Whether angiotensin converting-enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) are useful in high risk patients without heart failure is unclear. We perform a meta-analysis of prospective randomized placebo-controlled ACEI or ARB trials studying patients with a combination of risk factors to assess treatment impact on all cause mortality, cardiovascular mortality, nonfatal myocardial infarction (MI) and stroke. Method. A PubMed search was made for placebo-controlled trials recruiting at least 1,200 high risk patients randomized to either ACEI or ARB, with follow-up of at least 2 years. Meta-analysis was performed using the RevMan 5 program and Mantel-Haenszel analysis was done with a fixed effects model. Results. Ten trials recruiting 77,633 patients were reviewed. All cause mortality was significantly reduced by ACEI (RR 0.89; ), but not by ARB treatment (RR 1.00; ). Cardiovascular mortality and nonfatal MI were also reduced in the ACEI trials but not with ARB therapy. Stroke was significantly reduced in the ACEI trials (RR 0.75; ) and more modestly reduced in the ARB trials (RR 0.90; ). Conclusion. ACEI treatment reduced stroke, nonfatal MI, cardiovascular and total mortality in high risk patients, while ARB modestly reduced stroke with no effect on nonfatal MI, cardiovascular and total mortality. 1. Introduction Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) have been shown to reduce cardiovascular outcomes in patients with heart failure or hypertension [1–3]. However, whether ACEI and ARB are useful in reducing cardiovascular events amongst patients at risk from a variety of clinical conditions but without left ventricular systolic dysfunction is more debatable. Several meta-analyses have addressed this issue, but these solely reviewed either ACEI or ARB alone or looked at patients with a single disease condition like hypertension or ischemic heart disease [4–10]. Both ACEI and ARB produce inhibition of the rennin-angiotensin system and have been shown to be equivalent in their blood pressure lowering effect [11]. We thus seek to answer the question of whether ACEI and ARB are useful and equivalent in their reduction of total mortality, cardiovascular mortality, nonfatal myocardial infarction (MI), and stroke in patients with normal systolic function and who are at high risk of cardiovascular events from a combination of various clinical conditions. 2. Methods This present meta-analysis seeks to address the question of whether ACEI and ARB should be routinely used in patients at
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