Clinical Question: Are angiotensin-converting enzyme (ACE) inhibitors effective in decreasing mortality and morbidity in patients with heart disease who do not have heart failure or systolic dysfunction?

Setting: Outpatient (any)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: The authors conducting this meta-analysis searched four databases, secondary sources, and presentations at scientific meetings. They did not look for unpublished research. They included all randomized controlled studies of at least two years in length of patients with, or at high risk of, coronary artery disease (CAD) but without signs or symptoms of heart failure and no documented left ventricular dysfunction. The authors did not state whether the literature search and data abstraction were completed by more than one person. They combined the results from seven studies enrolling a total of 33,960 patients. Five ACE inhibitors were used in these studies.

Overall mortality was lower in patients receiving an ACE inhibitor than in those receiving placebo, although the effect on individual patients was small (number needed to treat [NNT] for two years = 419; 95% confidence interval [CI], 279 to 839). The number of deaths caused by cardiovascular effects also was decreased (NNT for two years = 720; CI, 507 to 1,370). Myocardial infarction risk and stroke risk were similarly decreased. These NNTs are high because of the relatively small benefit (12 to 14 percent reduction) and because the death rate in these studies was less than 2 percent. There was no correlation between blood pressure reduction and outcomes in this study.

Bottom Line: ACE inhibitors decrease overall mortality, cardiovascular mortality, myocardial infarction risk, and stroke risk in patients with CAD but who have no signs or symptoms of heart failure. The benefit is not pronounced, with only one death prevented in more than 400 patients treated for two years. (Level of Evidence: 1a)