What Is the Role of Renin Angiotensin System Inhibitors in Treating Stable Coronary Artery Disease?

February 7, 2017

What Is the Role of Renin Angiotensin System Inhibitors in Treating Stable Coronary Artery Disease?

  1. Joel M. Gore, MD

Results of a meta-analysis suggest that the current guideline recommendation for their use in most cases may need to be revisited.

  1. Joel M. Gore, MD

Based on early studies, current guidelines recommend renin angiotensin system (RAS) inhibitors for all patients with stable ischemic heart disease and any one of the following conditions: hypertension, diabetes, left ventricular ejection fraction (LVEF) ≤40%, or chronic kidney disease. To evaluate the impact of more-recent studies on the evidence base, researchers conducted a meta-analysis of randomized trials comparing RAS inhibitors with placebo or active controls in patients with stable coronary artery disease (CAD) without heart failure. Included were 24 trials involving 61,961 patients; average follow-up was 3.2 years. Eighteen trials were placebo-controlled, and seven had active controls (calcium-channel antagonists in 4, thiazide diuretics in 1, and conventional treatment in 2).

RAS inhibitors significantly reduced risk for the individual endpoints of all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, angina, heart failure, and revascularization when compared with placebo but not when compared with active controls. Furthermore, the beneficial effects on all-cause and cardiovascular mortality were found only when control-group event rates were high, and not when they were low. In a sensitivity analysis, the beneficial effect of RAS inhibitors in placebo-controlled trials was independent of baseline systolic blood pressure; in active-control trials, RAS inhibitors showed no benefit regardless of systolic blood pressure.

Comment

The lack of benefit with RAS inhibitors when compared with active controls, and the fact that the benefit in placebo-controlled trials was seen mainly when event rates in the control group were high — which has not been the case in recent studies — do not support a recommendation for the routine use of RAS inhibitors in patients with stable CAD. It is important to note that these results do not apply to patients with low LVEF or chronic kidney disease. For stable CAD patients with only hypertension or diabetes, however, clinicians may reasonably ask themselves whether an RAS inhibitor is necessary.

Editor Disclosures at Time of Publication

  • Disclosures for Joel M. Gore, MD at time of publication Grant / Research support NIH–National Heart, Lung, and Blood Institute

Citation(s):

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.