ACE Inhibitors Help All Heart Patients

Even Those With Moderate Risk or Already on Other Medications May Benefit, Study Shows

Medically Reviewed by Louise Chang, MD on August 10, 2006
From the WebMD Archives

Aug. 10, 2006 - Even moderate-risk heart patients already taking other medications to protect against heart attacks and strokes can benefit from adding an ACE inhibitor to the mix, a new analysis finds.

Researchers concluded that for every 1,000 patients treated with an ACE inhibitor for 4.5 years, 21 serious events such as heart attackor strokecould be prevented.

The analysis appears in the Aug. 12 issue of The Lancet.

ACE inhibitors are a class of medications widely prescribed for patients with heart failure and for other high-risk heart patients, such as those with diabetes.

Heart failure means the heart muscle's pumping strength has weakened. There are a number of causes for heart failure; having a heart attack is one.

It has been unclear if these drugs benefit patients who do not have heart failure but have atherosclerosis (hardening of the arteries), with a moderate-to-low risk of having a heart attack or stroke.

Three large studies conducted since the mid-1990s attempted to answer this question.

Revisiting the Data

Two studies found ACE inhibitors helped protect moderate-risk patients with hardening of the arteries, but not heart failure. One found no benefit.

In an effort to make sense of the seemingly paradoxical findings, researchers combined and reanalyzed the three trials, known individually as the HOPE, EUROPA, and PEACE studies.

The researchers concluded that the addition of an ACE inhibitor reduced the risk of death from any cause -- heart failure, heart attack, or stroke -- even among very low-risk patients and those taking other heart-protecting drugs like low-dose aspirin, cholesterol-lowering statins, and beta- blockers.

"Even the low-risk patients with heart diseasein these trials benefited," Gilles R. Dagenais, MD, one of the researchers, tells WebMD.

Analyzing the Benefits of ACE Inhibitors

The new analysis conflicts with the finding of the PEACE study investigators, who concluded ACE inhibitors were no better than a placebo for lowering the risk of heart attackin patients with stable coronary artery disease already taking other heart-protecting drugs.

At the time, PEACE researchers suggested the lack of benefit could be explained by the fact that their study included lower risk patients than the other two trials, and that more of their patients were taking statins to lower their LDL "bad" cholesterol.

But when Dagenais and colleagues controlled for these differences, they concluded this was not the case.

They found patients who had a very low risk of having a heart attack or stroke-- even those whose risk was as low as 1.7% per year - lowered the risk even further when they took an ACE inhibitor.

"The use of ACE inhibitors should be considered in all patients with vascular disease [atherosclerosis] as long as they can tolerate these agents and the absolute benefits are judged to be valuable," they write.

Second Opinion

Two drug researchers who weighed in on the issue in an editorial published with the study remain unconvinced.

Giuseppe Remuzzi and Piero Ruggenenti, of Italy's Mario Negri Institute for Pharmacological Research, take issue with the conclusions from the new analysis. They write that ACE inhibitors appear to offer "no added benefit to low-risk patients already on aspirin, beta blockers, and statins."

American Heart Association spokesman Richard Stein, MD, tells WebMD that patients with heart disease should discuss their treatment options with their doctor, including whether to add an ACE inhibitor to the drugs they are already taking.

Stein is director of preventive cardiology at New York City's Beth Israel Medical Center.

"The question, 'Do I add an ACE inhibitor to what I am already doing to reduce my risk?' is a reasonable one, and for many patients the answer will be 'yes,'" Stein says.

Show Sources

SOURCES: Dagenais, G.R. The Lancet, Aug. 12, 2006; vol 368: pp 581-588. Gilles R. Dagenais, MD, The Laval University Heart and Lung Institute, Laval Hospital, Quebec, Canada. Guiseppe Remuzzi, Mario Negri Institute for Pharmacological Research, Bergamo, Italy. Richard Stein, MD, director of preventive cardiology, Beth Israel Medical Center, New York, N.Y.; spokesman, American Heart Association.

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