Author + information
- Bora Toklu,
- Robert Fakheri,
- Franz H. Messerli and
- Sripal Bangalore
Background: Renin angiotensin system inhibitors (RASi) are recommended (Class I LoE A) for patients with coronary artery disease (CAD) without heart failure. However, more recent trials with improved background therapy (and lower event rates) failed to show a benefit of RASi over active controls or placebo.
Methods: Trial level meta-analysis of randomized trials was performed. Pubmed/EMBASE/CENTRAL databases searched for randomized trials of RASi vs. placebo/active controls in patients with CAD and preserved left ventricular function. Outcomes were death, cardiovascular death, myocardial infarction (MI), angina, stroke, heart failure, revascularization, incident diabetes and drug withdrawal due to adverse effects.
Results: Twenty five trials with a total of 198,275 patient-years of follow-up satisfied our inclusion criteria. RASi reduced the risk of all-cause mortality (RR=0.84; 95% CI 0.72-0.98), cardiovascular mortality (RR=0.74; 95% CI 0.59-0.94), MI (RR=0.82; 95% CI 0.76-0.88), stroke, angina, heart failure and revascularization only when compared with placebo but not when compared with active controls (for example- all-cause mortality RR=1.05; 95% CI 0.94-1.17 (Pinteraction=0.006)). The effect of RASi on all-cause mortality and cardiovascular mortality depended on the control event rate (P <0.05) such that RASi was only beneficial in trials with high control event rate but not in those with low control event rate.
Conclusions: In patients with CAD and preserved left ventricular function, RASi reduced cardiovascular events and death only when compared with placebo but not when compared with active (largely calcium antagonists- amlodipine). Moreover, the benefit of RASi was mainly seen in trials with higher control event rate but not in those with lower control event rate. RASi should no longer be considered preferred therapy in CAD patients with preserved left ventricular function.
Poster Hall, Hall C
Friday, March 17, 2017, 10:00 a.m.-10:45 a.m.
Session Title: Traditional and Novel Factors Used to Assess the Risk of, and Used for the Treatment of, Coronary Artery Disease
Abstract Category: 2. Acute and Stable Ischemic Heart Disease: Clinical
Presentation Number: 1126-348
- 2017 American College of Cardiology Foundation