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Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease

• CME Information
• Faculty Biographies & Disclosures
• References
• Course Presentations
• CME Posttest

CME Information

Course Overview Educational Objectives Target Audience Method of Participation

Accreditation Statement Term of Approval Peer Review Program Director

Disclaimer Disclosure Acknowledgement of Support

Course Overview

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are proven therapies that reduce morbidity and mortality in patients with chronic heart failure, those who are post-heart attack with left ventricular systolic dysfunction, or those with diabetes mellitus with proteinuria. It is less clear how ACEIs contribute to the reduction of cardiovascular events in patients with stable ischemic heart disease (IHD) who also have preserved left ventricular systolic function (LVSF), as determined by a left ventricular ejection fraction >40%. These patients have relatively intact LVSF, yet may have chest pain (angina pectoris) brought on by emotional or physical stress. These symptoms are usually due to one or more clogged or diseased arteries that result in reduced blood flow and oxygen supply to the heart. Therapies shown to reduce the risk for cardiovascular events in patients with IHD include aspirin, statins, ß-blockers, and dual antiplatelet therapy. Other agents used for symptomatic relief include nitrates and calcium channel blockers. A revascularization procedure to circumvent a blocked vessel is another therapeutic option for patients unresponsive or intolerant to these medications. A patient will need prolonged treatment with these medications to reduce anginal symptoms, increase quality of life, and reduce the risk of fatal and nonfatal cardiovascular events. Considerable research has been conducted to determine if there are additional cardiovascular benefits from adding ACEI and/or ARB therapy to the long-term care regimens for patients with stable IHD and intact LVSF, and if those benefits outweigh the potential side effects of these drugs.

This CME activity was developed from Coleman CI, Baker WL, Kluger J, Reinhart K, Talati R, Quercia R, Mather J, 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. Comparative Effectiveness Review No. 18. (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: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=335

This CME activity is one of two developed from this comparative effectiveness review. The second titled, Management of the Patient with Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function, is available at: http://staging.ehcmanagement.org/index.cfm/search-for-guides-reviews-and-reports/?&pageaction=displaycmeactivity&activityID=257

Educational Objectives

At the conclusion of this activity, the participant should be able to:

• Identify trade-offs in the benefits and harms of adding an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) to standard therapy for patients with stable ischemic heart disease (IHD) and preserved left ventricular systolic function (LVSF).
• Understand the benefits and harms associated with adding an ACEI/ARB combination to standard therapy for patients with stable IHD and preserved LVSF.
• Determine which patients with stable IHD and preserved LVSF are candidates for the addition of ACEIs or ARBs to their treatment regimen soon before undergoing a revascularization procedure.
• Communicate the critical evidence on benefits and harms to patients with stable IHD while exploring their specific values and encouraging them to be involved in their own care.

Target Audience

This CME activity is designed to meet the educational needs of physicians in cardiology and the primary care specialties, including family medicine, general practice, and internal medicine.

Method of Participation

This activity is in PowerPoint file format and is accompanied by talking points and references linked to PubMed abstracts.

To receive a maximum of 1.0 AMA PRA Category 1 Credit(s)™ you should:

• View the presentations in this enduring material.
• Complete the posttest (you must answer 8 out of 9 questions correctly).
• Complete and submit the CME registration and evaluation forms.

The estimated time to complete this activity, including review of the materials, is 1.0 hour(s).

Hardware/software requirements: Activities should be run with recent versions of common browsers, including Internet Explorer, Firefox, and Google Chrome.

If you have questions about the participation process, please e-mail the Office of Continuing Medical Education, cme@bcm.edu or phone 713.798.8237.

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.    

Term of Approval

July 2010 through July 2013. Original release date: July 2010

Peer Review

In October 2009, this continuing medical education online enduring material was reviewed by Vijay Nambi, M.D., an assistant professor in the Section of Atherosclerosis and Vascular Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas. It was also reviewed in November 2009 by Frank J. Domino, M.D., an associate professor in the Department of Family and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts. To ensure the continued scientific relevance of this enduring material, its content will be reviewed again in July 2011.

Disclosure: 
Vijay Nambi, MD: nonpublic support of research – Abbott, Genzyme, Gillson Longenbaugh Foundation, GlaxoSmithKline, Gulf Coast Regional Medical Foundation, ISIS, KOWA, Merck, NIH/NHLBI, Roche, Sanofi; speakers bureau membership – American Heart Association (Spotlight Series); board membership – American Society of Echocardiograhy (Vascular Council), National Lipid Association (Southwest Lipid Association officer), Society of Vascular Medicine.

Frank J. Domino, MD: advisory committee member – Pharmacy and Therapeutics Committee for MedMetrics (not for profit PBM).

Program Director

Glenn N. Levine, M.D., FACC, FAHA
Professor of Medicine
Baylor College of Medicine
Director, Cardiac Care Unit

Michael E. DeBakey Medical Center
Houston, Texas

Disclosure: nothing to disclose.

Disclaimer

This CME activity is designed for use by healthcare professionals for educational purposes only. Information and opinion offered by the contributors represent their viewpoints. Conclusions drawn by the participant should be derived from careful consideration of all available scientific information. Prescription information and use of medical devices should be undertaken only after confirmation of information by consulting the FDA-approved uses and information.

Baylor College of Medicine makes every effort to have accurate information presented, no warranty, expressed or implied, is offered. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Links are provided to other Internet sites solely for the convenience of users. Once you link to another site, you are subject to the site's terms and conditions of use including copyright and licensing restrictions.

Disclosure

The Office of Continuing Medical Education (OCME) makes every effort to develop CME activities that are scientifically based, accurate, current, and objectively presented. In accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support ^SM, Baylor College of Medicine (BCM) has implemented a mechanism requiring everyone in a position to control the content of an educational activity (e.g., directors, planning committee members, contributors, peer reviewers) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships: l) at the time of the activity or within 12 months prior; and 2) of their spouses/partners.

Baylor College of Medicine does not view the existence of interests or relationships with commercial entities as implying bias or decreasing the value of a presentation. It is up to the participants to determine whether the interests or relationships influence the presenter with regard to exposition or conclusions.

If at any time during this activity you feel that there has been commercial or promotional bias, please inform us by using the commercial bias comments box in the evaluation form. Please answer the questions about balance in the CME activity evaluation candidly.

The following individual(s) has/have reported financial or other relationship(s) with commercial entities whose products/services may relate to the educational content of this activity:

Frank J. Domino, M.D., Peer Reviewer: advisory committee membership – Chair, Pharmacy & Therapeutic Committee for Med Metrics (not-for-profit prescription benefit manager).

Vijay Nambi, M.D., Peer Reviewer: nonpublic grant support – Abbott, Genzyme, Gillson Longenbaugh Foundation, GlaxoSmithKline, Gulf Coast Regional Medical Foundation, ISIS, KOWA, Merck, NIH/NHLBI, Roche, Sanofi; speakers bureau membership – American Heart Association (Spotlight Series); board membership – American Society of Echocardiograhy (Vascular Council), National Lipid Association (Southwest Lipid Association officer), Society of Vascular Medicine.

Salim S. Virani, M.D., Contributor: speakers bureau membership – Abbott Laboratories, Daiichi Sankyo.

The following individual(s) has/have reported no financial or other relationships with commercial entities whose products/services may relate to the educational content of this activity:

William L. Baker, Pharm.D., BCPS, Contributor: nothing to disclose.
Craig I. Coleman, Pharm.D., Contributor: nothing to disclose.
Glenn N. Levine, M.D., Activity Director: nothing to disclose.
C. Michael White, Pharm.D., FCP, FCCP, Contributor: nothing to disclose.

Some drugs/devices identified during this activity may have United States Food and Drug Administration (FDA) clearance for specific purposes only or for use in restricted research settings. The FDA has stated that it is the responsibility of the individual physician to determine the FDA status of each drug or device that he/she wishes to use in clinical practice and to use the products in compliance with the applicable law.

Baylor College of Medicine requires that all contributors disclose an unlabeled use or investigational use (not yet approved for any purpose) of pharmaceutical and medical device products, and provide adequate scientific and clinical justification for such use. Physicians are urged to fully review all the available data on products or procedures before using them to treat patients.

Acknowledgement of Support

This activity is supported by a contract, HHSA290200810015C, from the Agency for Healthcare Research and Quality (AHRQ).

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