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Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

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Benefits With HIGH Levels of Evidence That Result From Adding an ACEI to Standard Medical Therapy for Stable Ischemic Heart Disease With Preserved Left Ventricular Systolic Function

On average, 91 patients with stable ischemic heart disease (IHD) and preserved left ventricular systolic function (LVSF) will need to be treated with an angiotensin-converting enzyme inhibitor (ACEI) over 4 years to prevent 1 additional death. In other words, on average, 8.5 in 100 patients with stable IHD will die in the next 4 years. If an ACEI were to be added to the treatment regimens of 100 patients, then 7.4 patients — or 1 less patient — will die. The absolute difference in event rates between the groups of patients who were treated or were not treated with an ACEI is 1.1, with a relative risk reduction in total mortality of 13%.

The benefits with respect to nonfatal myocardial infarction (MI) are similar. On average, 91 patients with stable IHD and preserved LVSF will need to be treated with an ACEI over 4 years to prevent 1 additional nonfatal MI. So, on average, 6.1 in 100 patients with stable IHD will have a nonfatal MI in the next 4 years. If an ACEI were to be added to the treatment regimens of 100 patients, then 5 patients — or 1 less patient — will have a nonfatal MI. The absolute difference in event rates between the two treatment groups is also 1.1, with a relative risk reduction in nonfatal MIs of 17%.

With regard to hospitalization for heart failure, on average, 167 patients with stable IHD and preserved LVSF will need to be treated with an ACEI over 4 years to prevent 1 additional hospitalization. On average, 2.6 in 100 patients with stable IHD will be hospitalized for heart failure-related reasons in the next 4 years. If an ACEI were to be added to the treatment regimens of 100 patients, then 2 patients — or nearly 1 less — would be hospitalized for heart failure-related reasons. The absolute difference in event rates between the two treatment groups is less than 1, with a relative risk reduction of 22% for heart failure-related hospitalizations.

Finally, on average, 77 patients with stable IHD and preserved LVSF will need to be treated with an ACEI over 3.7 years to prevent 1 additional revascularization surgery. Stated another way, on average, 13.6 in 100 patients with stable IHD will need revascularization surgery in the next 4 years. If an ACEI were to be added to the treatment regimens of 100 patients, then 12.3 patients — or about 1 less patient — would need this surgery. The absolute difference in event rates between the two treatment groups is 1.3, with a relative risk reduction of 10% for revascularization surgery.

Overall, the absolute difference in event rates between the patients treated with an ACEI and those who received standard treatment alone is 1.3 or less. Moreover, the addition of an ACEI did not significantly reduce atrial fibrillation or angina-related hospitalizations. All of these data were determined to be at a high level of evidence, meaning that future trials are unlikely to change the estimated differences between these treatment groups.