In patients with stable coronary artery disease without heart failure, renin angiotensin system inhibitors (RASIs) reduced cardiovascular events and all-cause mortality in comparison with placebo groups but not with active controls, according to a study published in BMJ.
Sripal Bangalore, MD, from the New York University School of Medicine in New York City, and colleagues searched for randomized controlled trials of RASIs in patients with coronary artery disease without heart failure. Primary outcomes evaluated were all-cause mortality, cardiovascular death, myocardial infarction, stroke, angina pectoris, and heart failure. Secondary outcomes evaluated were revascularization, incident diabetes, and drug withdrawal due to adverse effects.
The search included 24 trials that enrolled 61,961 patients who were followed up for an average of 3.2 years for a total of 198,275 patient years of follow-up. Of the included trials, 5 enrolled patients within 3 months of acute myocardial infarction, 18 were placebo controlled, and 7 were active controlled.
RASIs reduced the risk of all-cause mortality when compared with placebo (rate ratio, 0.84) but not when compared with active controls (1.05). Cardiovascular mortality was reduced when compared with placebo (0.74) but not with active controls (1.08). Myocardial infarction was reduced when compared with placebo (0.82) but not with active controls (0.99). RASIs were beneficial when compared with placebo mainly in trials with a greater difference in systolic blood pressure at the end of the trial. RASIs reduced the risk of stroke, angina, heart failure, revascularization, incident diabetes, and drug withdrawal when compared with placebo but not with active controls.
“Although RASIs reduced the risk of cardiovascular events when compared with placebo, no such benefit was seen when compared with active controls,” said the authors. “The blanket recommendation to use RASIs for all patients with coronary artery disease is not supported by evidence.”
- Bangalore S, Fakheri R, Wandel S, et al. Renin angiotensin system inhibitors for patients with stable coronary artery disease without heart failure: systematic review and meta-analysis of randomized trials. BMJ. doi: 10.1136/bmj.j4.