NEW YORK (Reuters Health) – The results of a systematic review suggest that use of an ACE inhibitor reduces total mortality and the risk of nonfatal MI in patients with ischemic heart disease and preserved ventricular function.

The benefits of angiotensin II-receptor blockers (ARBs) in this setting are less clear, according to the report in the October 20th online issue of the Annals of Internal Medicine. Moreover, adding an ARB to ACE inhibitor therapy does not improve outcomes and only increases adverse effects.

ARBs and ACE inhibitors are typically used to treat patients with reduced ventricular function or overt heart failure. Whether these drugs should be given to patients with preserved ventricular function is unclear, Dr. William L. Baker and colleagues, from the University of Hartford, Connecticut, note.

In searching MEDLINE, EMBASE, and Cochrane databases, the researchers identified 41 studies that examined the use of ARBs, ACE inhibitors, or both for heart disease with preserved ventricular function. The studies were at least 6 months’ duration and compared the intervention drugs with placebo or active controls.

Moderate- to high-strength evidence (7 trials featuring 32,559 patients) indicated that ACE inhibitor use reduced the relative risks of total mortality by 13% and nonfatal MI by 17%. At the same time, however, these agents increased the odds of syncope and cough by 24% and 67%, respectively.

Low-strength evidence (1 trial with 5926 subjects) showed that ARB use reduced the risk of the composite outcome of cardiovascular mortality, nonfatal MI, or stroke by 12%. Use of these drugs, however, did not cut the risk of each individual outcome.

Moderate-strength evidence (1 trial with 25,620 participants) suggested that ARB plus ACE inhibitor therapy was just as effective as ACE inhibitor therapy alone at cutting the risks of total mortality and MI. The combination, however, increased the risks of hypotension (p < 0.001) and syncope (p = 0.035). “Adding an ACE inhibitor to standard medical therapy improves clinical outcomes in some patients with stable ischemic heart disease and preserved left ventricular function,” the authors conclude. They add, however, that adding an ARB to ACE inhibitor therapy “seems no better than ACE inhibitor therapy alone and increases harms,” and that further studies are needed to more clearly define the role, if any, of ARBs in this patient population. Reference:
Ann Intern Med 2009.