Excerpt

This is an evidence report prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center (EPC) concerning the benefits and harms associated with using angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), either alone or in combination, in people with stable ischemic heart disease or ischemic heart disease risk equivalents and intact left ventricular systolic function.

While the role of ACE inhibitors and ARBs in patients with post-myocardial infarction left ventricular dysfunction or chronic heart failure is well established, the role for these modalities in patients with stable ischemic heart disease or ischemic heart disease risk equivalents and preserved left ventricular systolic function is not as clear. The aim of this report is to acquire, assess, and summarize the current evidence about the benefits and harms associated with the use of ACE inhibitors and ARBs, either alone or in combination, in this patient population. The information is intended to inform clinicians, payors, and the public, while helping to define avenues for future research.

Contents

• Preface
• Acknowledgments
• Executive Summary
  • Background
  • Conclusions
  • Remaining Issues
  • Future Research
• Introduction
  • Background
  • Scope and Key Questions
• Methods
  • Topic Development
  • Search Strategy
  • Study Selection
  • Data Extraction
  • Individual Study and Systematic Review Validity Assessment
  • Applicability
  • Rating the Strength of a Body of Evidence
  • Data Synthesis
  • Peer Review and Public Commentary
• Results
  • Results of Primary Literature Review
  • Results of Search and Quality of Existing Systematic Reviews
  • Key Question 1. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function, what is the comparative effectiveness of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization revascularization, and quality of life measures?
  • Key Question 2. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function and are receiving standard medical therapy, what is the comparative effectiveness of combining ACE inhibitors and ARBs versus either an ACE inhibitor or ARB alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization, revascularization, and quality of life measures?
  • Key Question 3. In patients with ischemic heart disease and preserved left ventricular function who had to have recently undergone, or are set to undergo, a coronary revascularization procedure, what is the comparative effectiveness of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone in terms of total mortality, cardiovascular mortality, nonfatal myocardial infarction, stroke, the composite endpoint of the latter three items, and atrial fibrillation? What is the evidence of benefit on other outcomes such as symptom reporting, hospitalization, revascularization, and quality of life measures?
  • Key Question 4. In patients with stable ischemic heart disease or ischemic heart disease risk equivalents who have preserved left ventricular systolic function, what are the comparative harms of adding ACE inhibitors or ARBs to standard medical therapy when compared to standard medical therapy alone?
  • Key Question 5. In patients with stable ischemic heart disease who have preserved left ventricular systolic function and are receiving standard medical therapy, what is the evidence of comparative harms of combination ACE inhibitor and ARB therapy versus use with either an ACE inhibitor or ARB alone?
  • Key Question 6. In patients with ischemic heart disease and preserved left ventricular systolic function who had to have recently undergone, or are set to undergo, a coronary revascularization procedure, what are the comparative harms of ACE inhibitors or ARBs added to standard medical therapy when compared to standard medical therapy alone?
  • Key Question 7. What is the evidence that benefits or harms differ by subpopulations, including: demographics [sex, age, ethnicity, left ventricular ejection fraction (LVEF)], clinical course (previous treatment with a stent or coronary artery bypass surgery, degree and location of lesion, presence and pattern of symptoms), dose of the ACE inhibitor or ARB used, co-morbidities (diabetes, renal dysfunction, hypertension), and other medications (vitamins, lipid lowering drugs, beta-blockers, anti-platelet agents)?
• Summary and Discussion
• Future Research
• References
• Abbreviations
• Appendixes
  • Appendix A Search Strategies
  • Appendix B List of Excluded Studies
  • Appendix C Additional Evidence Tables and Analyses
  • Appendix D Peer Reviewers
  • Appendix E Abstraction Forms

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.¹ Contract No. 290-2007-10067-I. Prepared by: University of Connecticut/Hartford Hospital Evidence-based Practice Center.

Suggested citation:

Coleman CI, Baker WL, Kluger J, Reinhart K, Talati R, Quercia R, MatherJ, Giovenale S, White CM. Comparative Effectiveness of Angiotensin Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease. (Prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center under Contract No. 290-2007-10067-I.) Rockville, MD: Agency for Healthcare Research and Quality. October 2009. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the University of Connecticut/Hartford Hospital Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10067-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

Craig I. Coleman, Pharm.D., has been a primary investigator on projects sponsored by Boehringer-Ingelheim Pharmaceuticals, the makers of the angiotensin receptor blocker telmisartan, but none of the projects were related to ischemic heart disease, angiotensin receptor blockers, or telmisartan. Dr. Coleman was not involved in the data extraction, analysis, or synthesis of the two key questions involving trials including telmisartan. None of the other investigators has any affiliations or financial involvement that conflicts with the material presentedin this report.

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