AHRQ Effective Health Care Program - Research Reviews

Comparative Effectiveness of Angiotensin Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease
Final Research Review published 20 Oct 2009

Background
Nearly 2,400 Americans die of cardiovascular disease each day, an average of one death every 36 seconds. Cardiovascular disease claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined. An estimated 79,400,000 American adults (one in three), of whom 37,500,000 are estimated to be age 65 or older, have one or more types of cardiovascular disease. Approximately 8,900,000 adults suffer from angina. Since 1900, cardiovascular disease has accounted for more deaths than any other single cause or group of causes of death in the United States in every year except one.

Based on clinical trial evidence, American College of Cardiology and American Heart Association guidelines support the use of angiotensin converting enzyme (ACE) inhibitors in patients who have chronic heart failure or those with myocardial infarction and left ventricular dysfunction, while angiotensin receptor blockers (ARBs) are reserved for those who cannot tolerate ACE inhibitors. Combined ACE inhibitor and ARB therapy has been shown to provide additional benefits over therapy with an ACE inhibitor alone among patients with heart failure. However, the combined use of an ACE inhibitor and ARB in post-myocardial-infarction patients with left ventricular dysfunction or heart failure was no better than the use of captopril alone and carried an increased risk of harms. Studies have been conducted that evaluate the use of ACE inhibitors and ARBs, either alone or in combination, in patients who have ischemic heart disease or an ischemic heart disease risk equivalent but without heart failure or left ventricular dysfunction. From this body of evidence, the benefits and harms associated with use of these therapies in this population of patients may be discerned.

This report summarizes the available evidence comparing the efficacy and safety of using ACE inhibitors, ARBs, or their combination vs. standard medical therapy in a population with stable ischemic heart disease, or an ischemic heart disease risk equivalent, and preserved left ventricular function. This report addresses the following questions:

Key Question 1. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function, what is the comparative effectiveness of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization, revascularization, and quality of life measures?

Key Question 2. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function and are receiving standard medical therapy, what is the comparative effectiveness of combining ACE inhibitors and ARBs vs. either an ACE inhibitor or ARB alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization, revascularization, and quality of life measures?

Key Question 3. In patients with ischemic heart disease and preserved left ventricular function who had to have recently undergone, or are set to undergo, a coronary revascularization procedure, what is the comparative effectiveness of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization, revascularization, and quality of life measures?

Key Question 4. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function, what are the comparative harms of adding ACE inhibitors or ARBs to standard medical therapy when compared to standard medical therapy alone?

Key Question 5. In patients with stable ischemic heart disease who have preserved left ventricular systolic function and are receiving standard medical therapy, what is the evidence of comparative harms of combination ACE inhibitor and ARB therapy vs. use with either an ACE inhibitor or ARB alone?

Key Question 6. In patients with ischemic heart disease and preserved left ventricular systolic function who had to have recently undergone, or are set to undergo, a coronary revascularization procedure, what are the comparative harms of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone?

Key Question 7. What is the evidence that benefits or harms differ by subpopulations, including: demographics [sex, age, ethnicity, left ventricular ejection fraction (LVEF)], clinical course (previous treatment with a stent or coronary artery bypass surgery, degree and location of lesion, presence and pattern of symptoms), dose of the ACE inhibitor or ARB used, comorbidities (diabetes, renal dysfunction, hypertension), and other medications (vitamins, lipid lowering drugs, beta-blockers, anti-platelet agents)?


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AHRQ Effective Health Care Program - Research Reviews