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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Angiotensin-Converting Enzyme Inhibitors in Coronary Artery Disease and Preserved Left Ventricular Systolic Function

A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Mouaz H. Al-Mallah, MD^_*,_*, Imad M. Tleyjeh, MD, Ahmed A. Abdel-Latif, MD and W. Douglas Weaver, MD, FACC^_*

^_* Division of Cardiology, Henry Ford Heart and Vascular Institute, Detroit, Michigan
Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
Division of Cardiology, University of Louisville, Louisville, Kentucky

Manuscript received August 2, 2005; revised manuscript received November 22, 2005, accepted November 28, 2005.

^_* Reprint requests and correspondence: Dr. Mouaz Al-Mallah, Henry Ford Heart and Vascular Institute, 2799 West Grand Boulevard, K 14, Detroit, Michigan 48202 (Email: malmall1{at}hfhs.org).

OBJECTIVES: This study sought to assess the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in patients with coronary heart disease and preserved left ventricular (LV) function.

BACKGROUND: The ACEIs have been shown to improve outcomes in patients with heart failure and myocardial infarction (MI). However, there is conflicting evidence concerning the benefits of ACEIs in patients with coronary artery disease (CAD) and preserved LV systolic function.

METHODS: An extensive search was performed to identify randomized, placebo-controlled trials of ACEI use in patients with CAD and preserved LV systolic function. Of 61 potentially relevant articles screened, 6 trials met the inclusion criteria. They were reviewed to determine cardiovascular mortality, nonfatal MI, all-cause mortality, and revascularization rates. We performed random-effect model meta-analyses and quantified between-studies heterogeneity with I².

RESULTS: There were 16,772 patients randomized to ACEI and 16,728 patients randomized to placebo. Use of ACEIs was associated with a decrease in cardiovascular mortality (relative risk [RR] 0.83, 95% confidence interval [CI] 0.72 to 0.96, p = 0.01), nonfatal MI (RR 0.84, 95% CI 0.75 to 0.94, p = 0.003), all-cause mortality (RR 0.87, 95% CI 0.81 to 0.94, p = 0.0003), and revascularization rates (RR 0.93, 95% CI 0.87 to 1.00, p = 0.04). There was no significant between-studies heterogeneity. Treatment of 100 patients for an average duration of 4.4 years prevents either of the adverse outcomes (one death, or one nonfatal myocardial infarction, or one cardiovascular death or one coronary revascularization procedure).

CONCLUSIONS: The cumulative evidence provided by this meta-analysis shows a modest favorable effect of ACEIs on the outcome of patients with CAD and preserved LV systolic function.

Abbreviations and Acronyms   ACEI = angiotensin-converting enzyme inhibitor   CAD = coronary artery disease   LV = left ventricular   MI = myocardial infarction   PCI = percutaneous coronary intervention

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