Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials.
OBJECTIVE
This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes.


BACKGROUND
Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established.


METHODS
The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups.


RESULTS
Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality.


CONCLUSIONS
Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.
Southern California Evidence-Based Practice Center, RAND Health, Santa Monica, California 90407-2138, USA. shekelle@rand.org
Paul G
PG
Shekelle
Michael W
MW
Rich
Sally C
SC
Morton
Col Sid W
CS
Atkinson
Wenli
W
Tu
Margaret
M
Maglione
Shannon
S
Rhodes
Michael
M
Barrett
Gregg C
GC
Fonarow
Barry
B
Greenberg
Paul A
PA
Heidenreich
Tom
T
Knabel
Marvin A
MA
Konstam
Anthony
A
Steimle
Lynne
L
Warner Stevenson
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000235:genetics*; D005260:Female; D006801:Humans; D008297:Male; D044469:Racial Groups / Q000235:genetics*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012737:Sex Factors; D015996:Survival Rate; D013599:Systole / Q000187:drug effects*; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology*
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors