Renin Angiotensin System Inhibitors for Patients with Stable Coronary Artery Disease without heart failure: Systematic Review and Meta-Analysis of Randomized Trials

Bangalore, Sripal; Fakheri, Robert; Wandel, Simon; Toklu, Bora; Wandel, Jasmin; Messerli, Franz H. (2017). Renin Angiotensin System Inhibitors for Patients with Stable Coronary Artery Disease without heart failure: Systematic Review and Meta-Analysis of Randomized Trials British medical journal, 356, j4. 10.1136/bmj.j4

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Objective: To critically evaluate the efficacy of renin angiotensin system inhibitors (RASi) in patients with coronary artery disease without heart failure, compared with active controls or placebo. Design: Meta-analysis of randomized trials. Data sources: PubMed, EMBASE, and CENTRAL databases until 1 May 2016. Eligibility criteria for selecting studies: Randomized trials of RASi versus placebo or active controls in patients with stable coronary artery disease without heart failure (defined as left ventricular ejection fraction ≥40% or without clinical heart failure). Each trial had to enroll at least 100 patients with coronary artery disease without heart failure, with at least one year’s follow-up. Studies were excluded if they were redacted or compared use of angiotensin converting enzyme inhibitors with angiotensin receptor blockers. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, incident diabetes, and drug withdrawal due to adverse effects. Results: 24 trials with 198 275 patient years of follow-up were included. RASi reduced the risk of all cause mortality (rate ratio 0.84, 95% confidence interval 0.72 to 0.98), cardiovascular mortality (0.74, 0.59 to 0.94), myocardial infarction (0.82, 0.76 to 0.88), stroke (0.79, 0.70 to 0.89), angina, heart failure, and revascularization when compared with placebo but not when compared with active controls (all cause mortality, 1.05, 0.94 to 1.17; Pinteraction=0.006; cardiovascular mortality, 1.08, 0.93 to 1.25, Pinteraction<0.001; myocardial infarction, 0.99, 0.87 to 1.12, Pinteraction=0.01; stroke, 1.10, 0.93 to 1.31; Pinteraction=0.002). Bayesian meta-regression analysis showed that the effect of RASi when compared with placebo on all cause mortality and cardiovascular mortality was dependent on the control event rate, such that RASi was only beneficial in trials with high control event rates (>14.10 deaths and >7.65 cardiovascular deaths per 1000 patient years) but not in those with low control event rates. Conclusions: In patients with stable coronary artery disease without heart failure, RASi reduced cardiovascular events and death only when compared with placebo but not when compared with active controls. Even among placebo controlled trials in this study, the benefit of RASi was mainly seen in trials with higher control event rates but not in those with lower control event rates. Evidence does not support a preferred status of RASi over other active controls.

Item Type:	Journal Article (Original Article)
Division/Institute:	School of Engineering and Computer Science > Institut für Optimierung und Datenanalyse IODA School of Engineering and Computer Science
Name:	Bangalore, Sripal; Fakheri, Robert; Wandel, Simon; Toklu, Bora; Wandel, Jasmin and Messerli, Franz H.
ISSN:	1756-1833
Submitter:	Service Account
Date Deposited:	19 Aug 2019 16:19
Last Modified:	04 Oct 2019 14:29
Publisher DOI:	10.1136/bmj.j4
Related URLs:	Publication
ARBOR DOI:	10.24451/arbor.5475
URI:	https://arbor.bfh.ch/id/eprint/5475