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
Overall Summary of the Evidence-Based Benefits and Harms of Adding an ACEI/ARB Combination Versus an ACEI Alone to Standard Medical Therapy for Stable Ischemic Heart Disease With Preserved Left Ventricular Systolic Function
This slide summarizes the detailed evidence from the Comparative Effectiveness Review (CER) with regard to combination therapy with an angiotensin-converting enzyme inhibitor (ACEI) and an angiotensin II receptor blocker (ARB). In the only trial available for analysis, the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET; Yusuf et al., 2008), an ACEI/ARB combination (ramipril + telmisartan) was added to standard medical therapy for patients with stable ischemic heart disease (IHD) and a preserved left ventricular systolic function (LVSF) and compared to the addition of only an ACEI (ramipril). ONTARGET also compared ramipril to telmisartan (ARB); this, however, was not part of the analysis of this CER and will not be discussed in this slide.
Based on the analysis of this single trial, the CER found no evidence that adding an ACEI/ARB combination to standard therapy provides any additional clinical benefit to patients with stable IHD and preserved LVSF when compared to adding an ACEI alone with regard to total mortality, cardiovascular mortality, fatal + nonfatal myocardial infarction, fatal + nonfatal stroke, the composite risk of the previous three outcomes, new atrial fibrillation, worsening or new angina, hospitalizations for angina, heart failure-related hospitalizations, or revascularizations. The level of evidence for these findings was deemed to be moderate. However, there also is a moderate level of evidence that there is an increased risk for the adverse events listed in this slide when ACEIs and ARBs are combined. The incidences of cough and angioedema did not reach statistical significance between the two treatment groups. The incidences of rash and blood dyscrasias were not reported in the original trial report.
- Agency for Healthcare Research and Quality. Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews, Version 1.0 [Draft posted Oct. 2007]. Rockville, MD.
- Coleman CI, Baker WL, Kluger J, et al. 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.
- Yusuf S, Teo KK, Pogue J, et al, for the ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. New Engl J Med 2008;358:1547-59.
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