Are angiotensin-converting enzyme inhibitors effective in decreasing mortality and morbidity in patients with heart disease but without heart failure or systolic dysfunction?

Angiotensin-converting enzyme (ACE) inhibitors decrease overall mortality, cardiovascular mortality, myocardial infarction risk, and stroke risk in patients with coronary artery disease (CAD) but without signs or symptoms of heart failure. The benefit is not pronounced, with only 1 death prevented in more than 400 patients treated for 2 years. (LOE = 1a)

Danchin N, Cucherat M, Thuillez C, Durand E, Kadri Z, Steg PC. Angiotensin-converting enzyme inhibitors in patients with coronary artery disease and absence of heart failure or left ventricular systolic dysfunction. Arch Intern Med 2006;166:787-796.  [PMID:16606817]

Meta-analysis (randomized controlled trials)

Unknown/not stated

Outpatient (any)

The French authors conducting this meta-analysis searched 4 databases, secondary sources, and presentations at scientific meetings. They did not look for unpublished research. They included all randomized controlled studies of at least 2 years in length of patients with CAD (or at high risk of CAD) but without signs or symptoms of heart failure and no documented left ventricular dysfunction. The authors did not state whether the literature search and data abstraction were performed by more than one person, which is the usual technique in meta-analysis. They combined the results from 7 studies enrolling a total of 33,960 patients. Five different ACE inhibitors were used in these studies. Overall mortality was lower in patients receiving an ACE inhibitor than in those receiving placebo, though the effect on the individual was small (number needed to treat [NNT] for 2 years = 419; 95% CI, 279-839). Deaths due to cardiovascular effects were also decreased (NNT for 2 years = 720; 507-1370). Myocardial infarction risk and stroke risk, were similarly decreased. These NNTs are so high in because of the relatively small benefit (12% - 14% reduction) and because the death rate in these studies was less than 2%. There was no correlation between blood pressure reduction and the outcomes seen in this study.