Angiotensin-converting-enzyme ( ACE ) inhibitors reduce cardiovascular mortality and morbidity in patients with heart failure or left ventricular systolic dysfunction.

Researchers, led by Gilles R Dagenais of Laval University Heart and Lung Institute ( Canada ) undertook a systematic review of HOPE, EUROPA, and PEACE studies to determine the consistency with which ACE inhibitors reduce total mortality and fatal and non-fatal cardiovascular events.

These three large trials have assessed the effect of ACE inhibitors in stable patients without these conditions but with atherosclerosis.

The researchers computed cardiovascular outcomes and total mortality in the 29.805 patients of these three trials, randomly assigned an ACE inhibitor or placebo and followed up for a mean of about 4·5 years.

The analysis showed that ACE inhibitors significantly reduced all-cause mortality ( 7·8 vs 8·9%, p=0·0004 ), cardiovascular mortality ( 4·3 vs 5·2%, p=0·0002 ), non-fatal myocardial infarction ( 5·3 vs 6·4%, p=0·0001 ), all stroke ( 2·2 vs 2·8%, p=0·0004 ), heart failure ( 2·1 vs 2·7%, p=0·0007 ), coronary-artery bypass surgery ( 6·0 vs 6·9%, p=0·0036 ) but not percutaneous coronary intervention ( 7·4 vs 7·6%, p=0·481 ).

The composite outcomes of cardiovascular mortality, non-fatal myocardial infarction, or stroke occurred in 10·7% of the patients allocated ACE inhibitor and in 12·8% of those allocated placebo ( odds ratio, 0·82; p<0·0001 ).

According to authors, use of ACE inhibitors should be considered in all patients with atherosclerosis.

In an accompanying editorial, two Italian cardiologists cited the PEACE trial results to argue against routine use of ACE inhibitors in such cases.

Source: The Lancet, 2006


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