title: Renin angiotensin system inhibitors for patients with stable coronary artery disease without heart failure: systematic review and meta-analysis of randomized trials.
abstract: OBJECTIVE
  To critically evaluate the efficacy of renin angiotensin system inhibitors (RASi) in patients with coronary artery disease without heart failure, compared with active controls or placebo.
  
  
  METHODS
  Meta-analysis of randomized trials.
  
  
  METHODS
  PubMed, EMBASE, and CENTRAL databases until 1 May 2016.
  
  
  METHODS
  Randomized trials of RASi versus placebo or active controls in patients with stable coronary artery disease without heart failure (defined as left ventricular ejection fraction ≥40% or without clinical heart failure). Each trial had to enroll at least 100 patients with coronary artery disease without heart failure, with at least one year's follow-up. Studies were excluded if they were redacted or compared use of angiotensin converting enzyme inhibitors with angiotensin receptor blockers. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, incident diabetes, and drug withdrawal due to adverse effects.
  
  
  RESULTS
  24 trials with 198 275 patient years of follow-up were included. RASi reduced the risk of all cause mortality (rate ratio 0.84, 95% confidence interval 0.72 to 0.98), cardiovascular mortality (0.74, 0.59 to 0.94), myocardial infarction (0.82, 0.76 to 0.88), stroke (0.79, 0.70 to 0.89), angina, heart failure, and revascularization when compared with placebo but not when compared with active controls (all cause mortality, 1.05, 0.94 to 1.17; Pinteraction=0.006; cardiovascular mortality, 1.08, 0.93 to 1.25, Pinteraction<0.001; myocardial infarction, 0.99, 0.87 to 1.12, Pinteraction=0.01; stroke, 1.10, 0.93 to 1.31; Pinteraction=0.002). Bayesian meta-regression analysis showed that the effect of RASi when compared with placebo on all cause mortality and cardiovascular mortality was dependent on the control event rate, such that RASi was only beneficial in trials with high control event rates (>14.10 deaths and >7.65 cardiovascular deaths per 1000 patient years) but not in those with low control event rates.
  
  
  CONCLUSIONS
  In patients with stable coronary artery disease without heart failure, RASi reduced cardiovascular events and death only when compared with placebo but not when compared with active controls. Even among placebo controlled trials in this study, the benefit of RASi was mainly seen in trials with higher control event rates but not in those with lower control event rates. Evidence does not support a preferred status of RASi over other active controls.
authors.affiliation: New York University School of Medicine, New York, NY, USA sripalbangalore@gmail.com.
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
authors.affiliation: New York University School of Medicine, New York, NY, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Fakheri
authors.affiliation: Novartis Pharma AG, Basel, Switzerland.
authors.forename: Simon
authors.initials: S
authors.lastname: Wandel
authors.affiliation: Mount Sinai Beth Israel Medical Center, New York, NY, USA.
authors.forename: Bora
authors.initials: B
authors.lastname: Toklu
authors.affiliation: Institute for Risks and Extremes, Bern University of Applied Sciences, Switzerland.
authors.forename: Jasmin
authors.initials: J
authors.lastname: Wandel
authors.affiliation: University Hospital, Bern, Switzerland.|Mount Sinai, Icahn School of Medicine, New York, NY, USA.|Jagiellonian University Krakow, Poland.
authors.forename: Franz H
authors.initials: FH
authors.lastname: Messerli
mesh_terms: D000328:Adult; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001499:Bayes Theorem; D003324:Coronary Artery Disease / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012084:Renin-Angiotensin System / Q000187:drug effects; D016896:Treatment Outcome
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors