title: Efficacy of Angiotensin-Converting Enzyme Inhibitors and Angiotensin-Receptor Blockers in Coronary Artery Disease without Heart Failure in the Modern Statin Era: a Meta-Analysis of Randomized-Controlled Trials.
abstract: OBJECTIVE
  Current practice guidelines support the use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARBs) in patients with coronary artery disease (CAD) without heart failure (HF). However, a number of cited trials were performed prior to the era of prevalent statin use. Our objective was to evaluate the effectiveness of ACEi and ARBs in reducing cardiovascular events as well as the impact of statin therapy.
  
  
  METHODS
  We searched the MEDLINE and EMBASE databases for randomized-controlled trials (1/1/1980 - 8/31/2015) with ACEi or ARBs as the single intervention for patients with CAD without HF. We assessed the outcomes of non-fatal myocardial infarction (MI), stroke, cardiovascular mortality and all-cause mortality. The relationship between these outcomes and the percentages of patients on statin therapy was evaluated using meta-regression analysis.
  
  
  RESULTS
  A total of ten ACEi trials and five ARB trials were included for analysis, with 78,761 patients followed for a mean of 36 months. Treatment with ACEi was associated with decreased non-fatal MI (RR 0.83; 95 % CI 0.75-0.91), stroke (RR 0.76; 95 % CI 0.68-0.86), cardiovascular mortality (RR 0.83; 95 % CI 0.72-0.95), and all-cause mortality (RR 0.86; 95 % CI 0.80-0.93). Treatment with ARBs was associated only with a decreased incidence of stroke (RR 0.92; 95 % CI 0.87-0.98). When adjusted for statin use, there was a trend towards an attenuated effect of ACEi in reducing cardiovascular mortality with increased use of statins (p-value = 0.063).
  
  
  CONCLUSIONS
  In CAD patients without HF, ACEi, but not ARBs decreases the risk of non-fatal MI, cardiovascular mortality and all-cause mortality, while both ACEi and ARBs decrease the risk of stroke.
authors: Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Faculty Center, One Baylor Plaza MS: BCM 620, Houston, TX, 77030, USA. vlhoang@bcm.edu.
authors: Vu
authors: http://orcid.org/0000-0001-9709-5234
authors: V
authors: Hoang
authors: Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Faculty Center, One Baylor Plaza MS: BCM 620, Houston, TX, 77030, USA.
authors: Mahboob
authors: M
authors: Alam
authors: Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Faculty Center, One Baylor Plaza MS: BCM 620, Houston, TX, 77030, USA.
authors: Daniel
authors: D
authors: Addison
authors: Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Faculty Center, One Baylor Plaza MS: BCM 620, Houston, TX, 77030, USA.
authors: Francisco
authors: F
authors: Macedo
authors: Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development and Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
authors: Salim
authors: S
authors: Virani
authors: Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Faculty Center, One Baylor Plaza MS: BCM 620, Houston, TX, 77030, USA.
authors: Yochai
authors: Y
authors: Birnbaum
mesh_terms: D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D003324:Coronary Artery Disease / Q000188:drug therapy*; D005260:Female; D006333:Heart Failure / Q000188:drug therapy; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000188:drug therapy; D016896:Treatment Outcome
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: Angiotensin-converting enzyme inhibitors; Angiotensin-receptor blockers; Coronary artery disease; Statin