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Evidence summaries

The Effect on ACE Inhibitors on Mortality and Morbidity in Patients with Heart Failure

ACE inhibitors reduce total mortality and hospitalization for congestive heart failure in patients with symptomatic heart failure and reduced ejection fraction. Level of evidence: "A"

A prospective systematic review 1 assessing individual patient data of the SAVE, AIRE, TRACE and SOLVD trials included a total of 12 763 patients. The follow-up period averaged 35 months. In the three post-infarction trials mortality was lower with ACE inhibitors than with placebo (23.4% vs 29.1%, OR 0.74, 95% CI 0.66 to 0.83), as were rates of readmission for heart failure (11.9% vs 15.5%, OR 0.73, 95% CI 0.63 to 0.85), and reinfarction (10.8% vs 13.2%, OR 0.80, 95% CI 0.69 to 0.94). In all five trials the ACE inhibitor group had lower rates of death than the placebo group and lower rates for reinfarction, readmission for heart failure and the composite of these events (33.8% vs 41.0%, OR 0.72, 95% CI 0.67 to 0.78). The benefits of treatment on all outcomes were independent of age, sex, and baseline use of diuretics, aspirin, and beta-blockers.

Another systematic review 2 including 32 studies with a total of 7 105 subjects was abstracted in DARE. The death rate was 15.8% among patients receiving ACE inhibitors and 21.0% among controls (OR 0.77, 95% CI 0.67 to 0.88). Most of the benefit occurred in the first 90 days. 22.4% of the patients in the ACE inhibitor group died or were hospitalised for congestive heart failure compared to 32.6% of the controls (OR 0.65, 95% CI 0.57 to 0.74). The OR for total mortality in treated vs control patients with ejection fraction <0.25 was 0.69 (95% CI 0.57 to 0.85), whereas for those with EF>0.25 the OR was 0.98 (95% CI 0.78 to 1.23). For the combined endpoint of total mortality or hospitalisation for CHF, the OR for patients with EF <0.25 was 0.53 (95% CI 0.43 to 0.65) while that for patients with EF >0.25 was 0.85 (95% CI 0.69 to 1.04).

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References

  • Flather MD, Yusuf S, Køber L, Pfeffer M, Hall A, Murray G, Torp-Pedersen C, Ball S, Pogue J, Moyé L, Braunwald E. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet 2000 May 6;355(9215):1575-81. [PubMed]
  • Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995 May 10;273(18):1450-6. [PubMed] [DARE]

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