The Angiotensin-converting Enzyme Inhibition Post Revascularization Study (APRES)

Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers After Coronary Artery Bypass Graft Surgery: A Population-Based Cohort Study

BACKGROUND

The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) on major adverse cardiovascular events (MACE) in patients who undergo coronary artery bypass graft surgery is equivocal. This retrospective, population-based cohort study evaluated effect of exposure to an ACEI/ARB on MACE using linked administrative databases that included all cardiac revascularization procedures, hospitalizations, and prescriptions for the population of British Columbia, Canada.

METHODS AND RESULTS

All adults who underwent coronary artery bypass graft surgery between 2002 and 2020 were eligible. The primary outcome was time to MACE, defined as a composite of all-cause death, myocardial infarction, and ischemic stroke using Cox proportional hazards models with inverse probability treatment weighting. Included were 15 439 patients and 6191 (40%) were prescribed an ACEI/ARB. Mean age was 66 years, 83% were men, and 16% had heart failure (HF). Median exposure time was 40 months. Over the 5-year follow-up, 1623 MACE occurred. Impact of exposure was different for patients with and without HF (P <0.0001 for interaction). After probability-weighting and adjustment for relevant covariates, exposure to ACEI/ARBs was associated with a lower hazard of MACE in patients with HF at 1 year (hazard ratio, 0.13 [95% CI, 0.09-0.19]) and 5 years (hazard ratio, 0.36 [95% CI, 0.30-0.44]). In patients without HF, ACEI/ARBs had a lower hazard of MACE at 1 year (hazard ratio, 0.35 [95% CI, 0.27-0.46]) and 5 years (hazard ratio, 0.66 [95% CI, 0.58-0.76]).

CONCLUSIONS

In this population-based study, ACEI/ARBs were associated with a lower hazard of MACE in a cohort of patients post-coronary artery bypass graft surgery irrespective of HF status.

Impact of Renin-Angiotensin System Blockers on Mortality in Veterans Undergoing Cardiac Surgery

Background

Renin‐angiotensin system blockers (RASBs) have well‐validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30‐day and 1‐year mortality after cardiac surgery.

Methods and Results

The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10‐year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30‐day and 1‐year mortality than the preoperative exposure/no current exposure (30‐day hazard ratio [HR], 0.25; 95% CI, 0.19–0.33 [P<0.001] and 1‐year HR, 0.40; 95% CI, 0.33–0.48 [P<0.001] or no preoperative exposure/no current exposure (30‐day HR, 0.44; 95% CI, 0.32–0.60 [P<0.001] and 1‐year HR, 0.72; 95% CI, 0.62–0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30‐day (HR, 0.31; 95% CI, 0.14–0.71 [P=0.006]) and 1‐year (HR, 0.64; 95% CI, 0.53–0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group.

Conclusions

Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.

Beta-blockers and renin-angiotensin system inhibitors in acute myocardial infarction managed with inhospital coronary revascularization

Pivotal trials of beta-blockers (BB) and angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) in acute myocardial infarction (AMI) were largely conducted prior to the widespread adoption of early revascularization. A total of 15,073 patients with AMI who underwent inhospital coronary revascularization from January 2007 to December 2013 were analyzed. At 12 months, BB was significantly associated with a lower incidence of major adverse cardiovascular events (MACE, adjusted HR 0.80, 95% CI 0.70–0.93) and all-cause mortality (adjusted HR 0.69, 95% CI 0.55–0.88), while ACEI/ARB was significantly associated with lower all-cause mortality (adjusted HR 0.80, 95% CI 0.66–0.98) and heart failure (HF) hospitalization (adjusted HR 0.80, 95% CI 0.68–0.95). Combined BB and ACEI/ARB use was associated with the lowest incidence of MACE (adjusted HR 0.70, 95% CI 0.57–0.86), all-cause mortality (adjusted HR 0.55, 95% CI 0.40–0.77) and HF hospitalization (adjusted HR 0.64, 95% CI 0.48–0.86). This were consistent for left ventricular ejection fraction < 50% or ≥ 50%. In conclusion, in AMI managed with revascularization, both BB and ACEI/ARB were associated with a lower incidence of 12-month all-cause mortality. Combined BB and ACEI/ARB was associated with the lowest incidence of all-cause mortality and HF hospitalization.

Renin-Angiotensin System Blockade and Risk of Heart Failure After Myocardial Infarction Based on Left Ventricular Ejection Fraction: A Retrospective Cohort Study

INTRODUCTION

The goal of this study was to determine the association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and follow-up heart failure (HF) according to left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI).

METHODS

This cohort study used a retrospective registry of 8169 consecutive patients discharged with a diagnosis of AMI from two university hospitals in Spain between 2010 and 2016. We used a multivariable competing risk analysis, survival-time inverse probability weighting (IPW) propensity score adjusting, and propensity score matching (PSM) to investigate the association between ACEI/ARB treatment and follow-up HF.

RESULTS

During the follow-up (3.3 ± 2.2 years), 1296 patients were admitted for HF (5.2 per 100 person-years). ACEI/ARB use was not associated with fewer follow-up HF admissions in patients with LVEF > 40% (univariate analysis: sub-hazard ratio [sHR] 1.10; 95% confidence interval [CI] 0.95-1.27; p = 0.197; IPW adjusting analysis: sHR 1.11; 95% CI 0.95-1.29; p = 0.192; PSM analysis: sHR 1.12; 95% CI 0.92-1.36; p = 0.248). However, ACEI/ARB use was associated with a significant reduction in HF admission rates in patients with LVEF ≤ 40% (univariate analysis: HR 0.70; 95% CI 0.56-0.88; p = 0.003; IPW adjusting analysis: HR 0.64; 95% CI 0.50-0.83; p = 0.001; PSM analysis: HR 0.65; 95% CI 0.46-0.92; p = 0.014).

CONCLUSION

Among hospitalized survivors of AMI, the use of ACEIs/ARBs was associated with a lower risk of follow-up HF in patients with LVEF ≤ 40% but not in those with LVEF > 40%. Further prospective studies are needed to confirm our results.

Perioperative use of renin-angiotensin system inhibitors and outcomes in patients undergoing cardiac surgery

It remains disputable about perioperative use of renin-angiotensin system inhibitors (RASi) and their outcome effects. This multicenter retrospective cohort study examines association between use of perioperative RASi and outcomes in patients undergoing coronary artery bypass graft and/or valve surgery. After the exclusion, the patients are divided into 2 groups with or without preoperative RASi (PreRASi, n = 8581), or 2 groups with or without postoperative RASi (PostRASi, n = 8130). With using of propensity scores matching to reduce treatment selection bias, the study shows that PreRASi is associated with a significant reduction in postoperative 30-day mortality compared with without one (3.41% vs. 5.02%); PostRASi is associated with reduced long-term mortality rate compared with without one (6.62% vs. 7.70% at 2-year; 17.09% vs. 19.95% at 6-year). The results suggest that perioperative use of RASi has a significant benefit for the postoperative and long-term survival among patients undergoing cardiac surgery.

Renin-angiotensin system inhibitors (RASi) are beneficial in several classes of cardiovascular patients. However, whether their perioperative use is beneficial and/or safe in cardiac surgery is unclear. Here the authors perform a multicenter retrospective cohort study showing that preoperative and postoperative use of RASi is associated with reduction of mortality in patients undergoing cardiac surgery.

The benefit of angiotensin AT1 receptor blockers for early treatment of hypertensive patients

ESC guidelines for management of arterial hypertension allow one to choose among five classes of antihypertensive drugs indiscriminately. They are based on the principle that in the management of hypertensive patients, it is fundamental to reduce blood pressure (BP), independently of the utilized drug. However, it has been demonstrated that the renin-angiotensin system (RAS) plays a relevant role in the hypertensive-derived development and progression of organ damage. Thus, antihypertensive drugs interfering with the RAS should be preferred in preventing and reducing target organ damage. The availability of two classes of drugs, ACE-inhibitors and angiotensin AT1 receptor blockers (ARBs), both interfering with the RAS, makes the choice between them difficult. Both pharmacological strategies offer an effective BP control, and a substantial improvement of prognosis in different associated pathologies. Regarding cardiovascular prevention, ACE-inhibitors have an extensive scientific literature regarding utility in high-risk patients. Nevertheless, there is evidence to support the concept that in the early phases of organ tissue damage, the RAS is activated, but the ACE pathway producing angiotensin II is not always employed. Accordingly, ACE-inhibitors appear to be less effective, whereas ARBs have a greater beneficial action in the initial stages of atherosclerotic disease. Moreover, patients undergoing ARBs therapy show a substantially lower risk of therapy discontinuation when compared to those treated with ACE-inhibitors, because of a better tolerability. In conclusion, ACE-inhibitors should be used in patients who have already developed organ damage, but tolerate this drug well, while ARBs should be the first choice in naïve hypertensive patients without organ damage or at the initial stages of disease.

Tissue ACE Inhibitors for Secondary Prevention of Cardiovascular Disease in Patients With Preserved Left Ventricular Function: A Pooled Meta-analysis of Randomized Placebo-controlled Trials

Objective. A pooled meta-analysis of published, randomized placebo-controlled clinical trials to evaluate the role of tissue angiotensin-converting enzyme (ACE) inhibitors in secondary prevention of cardiovascular disease in patients with preserved left ventricular function. Sources. Peer-reviewed journals listed in Index Medicus/MEDLINE, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews. Study selection . Randomized placebo-controlled clinical trials of at least 12 months' duration, in patients with a prior cardiovascular event or at high risk for cardiovascular events, were analyzed. Data synthesis and analysis. A total of 31 555 patients (136 882 patient-years) from 4 trials were selected for the meta-analysis. Relative risk estimations were made using data pooled from these trials, and statistical significance was determined using the χ2 test. The number of patients needed to treat was also calculated for each outcome. Results. Tissue ACE inhibitors significantly reduced the risk of all-cause mortality, cardiovascular mortality, acute myocardial infarction, and stroke ( P < .001 for each). The need for invasive coronary revascularization was reduced ( P = .03), as was the risk of hospitalization for congestive heart failure ( P = .001). The occurrence of new-onset diabetes was also significantly reduced ( P < .001), but the risk of hospitalization for angina was not significantly affected ( P = .677). Treating about 100 patients for about 4.5 years would prevent 1 death, 1 non-fatal myocardial infarction, 1 cardiovascular death, or 1 invasive coronary revascularization. Conclusions. Tissue ACE inhibitors have demonstrated benefit when used for secondary prevention of cardiovascular disease in patients with preserved left ventricular function in randomized placebo-controlled clinical trials.

Role of ACE I/D gene polymorphisms on the effect of ramipril in inflammatory response and myocardial injury in patients undergoing coronary artery bypass grafts

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors block angiotensin II formation and release bradykinin, which is effective in the regulation of oxidoinflammatory injury. Some reports denote alterations in the effectiveness of ACE inhibitors in association with ACE insertion/deletion (I/D) gene polymorphisms. This study investigates the effects of ramipril on the oxidoinflammatory cytokines (IL-6, IL-8, TNF-alpha) and TnT (myocardial injury marker) and their alteration in association with ACE I/D gene polymorphisms.

METHODS

The study group (n = 51) patients received ramipril before coronary artery bypass grafting (CABG), while patients not receiving ramipril (n = 51) constituted the controls. TNFα, IL-6, and IL-8 were evaluated using ELISA and TnT by electrochemiluminescence methods before the induction of anesthesia (t1), at the 20th minute following cross-clamping (t2), at the end of the operation (t3), and at the 24th hour from the commencement of anesthesia (t4). Genotyping was performed by PCR.

RESULTS

Differences between the groups were significant at t4 for the TNFα and at t3 for IL-6 (p < 0.05). The TnT levels increased from t2 onward in the control group and were highest in t3. Changes in t3 and t4 values in both groups according to their t1 values were significant (p < 0.05). However, differences between the groups were insignificant (p > 0.05). The IL-6, IL-8, TNFα, and TnT serum levels had no correlation with the ACE I/D gene polymorphism.

CONCLUSION

Low cytokine and TnT levels in the study group, especially after cross-clamping, may indicate the protective effect of ramipril from oxidoinflammatory injury. This effect did not appear to be associated with the ACE I/D gene polymorphism.

Which patients should be on renin-angiotensin system blockers after coronary surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'which patients should be on renin-angiotensin system blockers after coronary surgery?' Using the reported search, 12 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The 12 studies included 5 prospective randomized controlled trials (RCTs) and 1 meta-analysis. One RCT of 2553 stable patients post-coronary artery bypass surgery (CABG) with left ventricular (LV) ejection fraction ≤40% showed that angiotensin-converting enzyme inhibition (ACEI) therapy can and probably should be delayed beyond 7 days due to increased cardiovascular morbidity and mortality associated with immediate postoperative initiation of ACEI treatment. Another study showed that the cardioprotective benefits of ACEI following CABG are persistent with respect to an LV ejection fraction below or above 40% and whether percutaneous coronary intervention (PCI) or CABG was performed. A large multicentre international study of 4224 patients undergoing CABG looking at a composite outcome of rates of cardiac, cerebral and renal events and in-hospital mortality showed that continuous treatment with ACEI compared with no ACEI was associated with reductions of risks of non-fatal events (P = 0.009, odds ratio 0.69, 95% confidence interval 0.52-0.91). Addition of ACEI de novo following surgery was also associated with significant reduction in the risk of the composite outcome (P = 0.004) and of a cardiovascular event (P = 0.04). We conclude that angiotensin-converting enzyme inhibitor treatment plays an important role in minimizing ischaemic events after CABG even in low-risk patients. The cardioprotective benefits of these drugs are persistent at mid- and long-term follow-up, with respect to LV ejection fraction below or above 40% and whether PCI or CABG was performed. Not only continuation of angiotensin-converting enzyme inhibition early after surgery but also adding ACEI de novo postoperatively can be associated with better cardiovascular and renal outcomes.

Coronary artery bypass graft: why is the saphenous vein prone to intimal hyperplasia?

Proliferation and migration of smooth muscle cells and the resultant intimal hyperplasia cause coronary artery bypass graft failure. Both internal mammary artery and saphenous vein are the most commonly used bypass conduits. Although an internal mammary artery graft is immune to restenosis, a saphenous vein graft is prone to develop restenosis. We found significantly higher activity of phosphatase and tensin homolog (PTEN) in the smooth muscle cells of the internal mammary artery than in the saphenous vein. In this article, we critically review the pathophysiology of vein-graft failure with detailed discussion of the involvement of various factors, including PTEN, matrix metalloproteinases, and tissue inhibitor of metalloproteinases, in uncontrolled proliferation and migration of smooth muscle cells towards the lumen, and invasion of the graft conduit. We identified potential target sites that could be useful in preventing and (or) reversing unwanted consequences following coronary artery bypass graft using saphenous vein.

Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.

Patterns of use of perioperative angiotensin-converting enzyme inhibitors in coronary artery bypass graft surgery with cardiopulmonary bypass: effects on in-hospital morbidity and mortality

BACKGROUND

Despite proven benefit in ambulatory patients with ischemic heart disease, the pattern of use of angiotensin-converting enzyme inhibitors (ACEIs) in coronary artery bypass graft surgery has been erratic and controversial.

METHODS AND RESULTS

This is a prospective observational study of 4224 patients undergoing coronary artery bypass graft surgery. The cohort included 1838 patients receiving ACEI therapy before surgery and 2386 (56.5%) without ACEI exposure. Postoperatively, the pattern of ACEI use yielded 4 groups: continuation, 915 (21.7%); withdrawal, 923 (21.8%); addition, 343 (8.1%); and no ACEI, 2043 (48.4%). Continuous treatment with ACEI versus no ACEI was associated with substantive reductions of risk of nonfatal events (adjusted odds ratio for the composite outcome, 0.69; 95% confidence interval, 0.52-0.91; P=0.009) and a cardiovascular event (odds ratio, 0.64; 95% confidence interval, 0.46-0.88; P=0.006). Addition of ACEI de novo postoperatively compared with no ACEI therapy was also associated with a significant reduction of risk of composite outcome (odds ratio, 0.56; 95% confidence interval, 0.38-0.84; P=0.004) and a cardiovascular event (odds ratio, 0.63; 95% confidence interval, 0.40-0.97; P=0.04). On the other hand, continuous treatment of ACEI versus withdrawal of ACEI was associated with decreased risk of the composite outcome (odds ratio, 0.50; 95% confidence interval, 0.38-0.66; P<0.001), as well as a decrease in cardiac and renal events (P<0.001 and P=0.005, respectively). No differences in in-hospital mortality and cerebral events were noted.

CONCLUSIONS

Our study suggests that withdrawal of ACEI treatment after coronary artery bypass graft surgery is associated with nonfatal in-hospital ischemic events. Furthermore, continuation of ACEI or de novo ACEI therapy early after cardiac surgery is associated with improved in-hospital outcomes.

Role of the renin-angiotensin system in the pathogenesis of intimal hyperplasia: therapeutic potential for prevention of vein graft failure?

The saphenous vein remains the most widely used conduit for peripheral and coronary revascularization despite a high rate of vein graft failure. The most common cause of vein graft failure is intimal hyperplasia. No agents have been proven to be successful for the prevention of intimal hyperplasia in human subjects. The renin-angiotensin system is essential in the regulation of vascular tone and blood pressure in physiologic conditions. However, this system mediates cardiovascular remodeling in pathophysiologic states. Angiotensin II is becoming increasingly recognized as a potential mediator of intimal hyperplasia. Drugs modulating the renin-angiotensin system include angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These drugs are powerful inhibitors of atherosclerosis and cardiovascular remodeling, and they are first-line agents for management of several medical conditions based on class I evidence that they delay progression of cardiovascular disease and improve survival. Several experimental models have demonstrated that these agents are capable of inhibiting intimal hyperplasia. However, there are no data supporting their role in prevention of intimal hyperplasia in patients with vein grafts. This review summarizes the physiology of the renin-angiotensin system, the role of angiotensin II in the pathogenesis of cardiovascular remodeling, the medical indications for these agents, and the experimental data supporting an important role of the renin-angiotensin system in the pathogenesis of intimal hyperplasia.

Impact of preoperative angiotensin-converting enzyme inhibitor use on clinical outcomes after cardiac surgery

BACKGROUND

Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) therapy is associated with adverse outcomes after coronary artery bypass grafting (CABG).

METHODS

We analyzed the outcomes of consecutive patients who underwent isolated CABG between 1998 and 2007 at a single institution. We used multivariable models to examine the association between preoperative ACEi therapy and in-hospital and long-term outcomes.

RESULTS

Of the 5946 patients undergoing isolated CABG during the study period, 3,262 (54.9%) were treated with an ACEi preoperatively and 2,684 (45.1%) were not. Median follow-up was 3.8 years. Patients treated with an ACEi preoperatively were more likely to have diabetes, hypertension, an ejection fraction of less than 40%, and recent myocardial infarction (all p<0.0001). They were less likely to have pre-existing renal failure (p=0.004) or require an urgent or emergent CABG (p=0.03). Postoperative use of an inotrope (26% vs 20%, p<0.0001) or intra-aortic balloon pump (1.8% vs 1.1%, p=0.03) was more frequent in patients treated preoperatively with an ACEi; however, preoperative ACEi use was not an independent predictor of in-hospital mortality (odds ratio [OR], 1.1; p=0.76), prolonged length of stay in the intensive care unit (OR, 0.9; p=0.09), or new-onset renal failure (OR, 0.7; p=0.09). Furthermore, preoperative use of an ACEi had no independent association with long-term survival (p=0.54) or freedom from acute coronary syndrome (p=0.07). However, it was associated with an increased risk of readmission for heart failure over time (hazard ratio, 1.2; p=0.007).

CONCLUSIONS

We found no association between preoperative ACEi therapy and adverse in-hospital outcomes or long-term survival after CABG. Preoperative ACEi therapy appears to be safe in patients undergoing CABG.

Should all patients be treated with an angiotensin-converting enzyme inhibitor after coronary artery bypass graft surgery? The impact of angiotensin-converting enzyme inhibitors, statins, and β-blockers after coronary artery bypass graft surgery

BACKGROUND

We sought to evaluate the association between angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass graft surgery (CABG).

METHODS

Postoperative outpatient utilization of ACE inhibitors, statins, and β-blockers was assessed in a cohort of 3,718 patients after CABG 65 years and older. The primary outcome was freedom from a composite of all-cause mortality or hospital readmission for cardiac events or procedures.

RESULTS

Use of all 3 medication classes increased significantly over the study period. Female patients and patients with a history of myocardial infarction, diabetes, and poor left ventricular function were independently associated with ACE inhibitor use on multivariate analysis (all P < .05). At a median follow-up of 3 years, postoperative therapy with an ACE inhibitor had no effect on death or rehospitalization for cardiovascular events (adjusted hazard ratio [HR] 1.12, 95% CI 0.96-1.30, P = .16). However, statins (HR 0.65, 95% CI 0.57-0.74, P < .0001) and β-blockers (HR 0.83, 95% CI 0.74-0.93, P = .001) were associated with a significantly improved event-free survival.

CONCLUSIONS

Among patients after CABG 65 years or older, ACE inhibitors had no independent effect on mortality or recurrent ischemic events in the midterm after CABG, although a benefit was observed for statins and β-blockers.

Meta-analysis of randomized controlled trials on effect of angiotensin-converting enzyme inhibitors on cancer risk

The renin-angiotensin system is an important mediator of tumor progression and metastasis. A recent meta-analysis of randomized controlled trials reported an increased risk of cancer with angiotensin receptor blockers. It is unknown whether angiotensin-converting enzyme (ACE) inhibitors may have a similar effect. Our primary objective was to determine the effect of ACE inhibitors on cancer occurrence and cancer death. Our secondary objective was to determine the effect of ACE inhibitors on occurrence of gastrointestinal (GI) cancers given previous concerns of increased risk. Systematic searches of SCOPUS (covering MEDLINE, EMBASE, and other databases) and the Food and Drug Administration official web site were conducted for all randomized controlled trials of ACE inhibitors. Trials with ≥1 year of follow-up and enrolling a minimum of 100 patients were included. Fourteen trials reported cancer data in 61,774 patients. This included 10 trials of 59,004 patients providing information on cancer occurrence, 7 trials of 37,515 patients for cancer death, and 5 trials including 23,291 patients for GI cancer. ACE inhibitor therapy did not have an effect on occurrence of cancer (I(2) 0%, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.95 to 1.07, p = 0.78), cancer death (I(2) 0%, RR 1.00, 95% CI 0.88 to 1.13, p = 0.95), or GI cancer (RR 1.09, 95% CI 0.88 to 1.35, p = 0.43). In conclusion, ACE inhibitors did not significantly increase or decrease occurrence of cancer or cancer death. There was also no significant difference in risk of GI cancer.

Imagine how many lives you save: angiotensin-converting enzyme inhibition for atherosclerotic vascular disease in the present era of risk reduction

INTRODUCTION

Angiotensin-converting enzyme (ACE) inhibition is clearly beneficial in patients with hypertension, heart failure, and post-myocardial infarction left ventricular (LV) dysfunction. However, whereas initial trials had reported a benefit of ACE inhibition in high-risk vascular patients, current trials of ACE inhibition have failed to demonstrate a clear benefit in vascular patients who are receiving risk-reduction interventions. The purpose of this review is to analyze the reasons behind the failure of the most recent trials of ACE inhibitors in vascular patients without overt LV dysfunction. The reader will gain an understanding of the time-dependent trend towards a reduction in the absolute benefit conferred by ACE inhibition in patients with vascular atherosclerosis as risk reduction interventions are increasingly implemented.

AREAS COVERED

Major trials with a follow-up period of at least 1 year assessing the use of ACE inhibitors in patients with a history of cardiac or vascular events were identified via a PubMed literature search. All-cause and cardiovascular mortality outcomes were reported for each trial, as well as the use of aspirin, lipid-lowering drugs and β-blockers, and the mean LV ejection fraction.

EXPERT OPINION

The findings of recent trials do not support the use of ACE inhibitors in vascular patients who, adherent with risk reduction therapy, do not have hypertension, diabetes, or LV dysfunction.

Antihypertensive drugs and risk of cancer: network meta-analyses and trial sequential analyses of 324,168 participants from randomised trials

BACKGROUND

The risk of cancer from antihypertensive drugs has been much debated, with a recent analysis showing increased risk with angiotensin-receptor blockers (ARBs). We assessed the association between antihypertensive drugs and cancer risk in a comprehensive analysis of data from randomised clinical trials.

METHODS

We undertook traditional direct comparison meta-analyses, multiple comparisons (network) meta-analyses, and trial sequential analyses. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from 1950, to August, 2010, for randomised clinical trials of antihypertensive therapy (ARBs, angiotensin-converting-enzyme inhibitors [ACEi], β blockers, calcium-channel blockers [CCBs], or diuretics) with follow-up of at least 1 year. Our primary outcomes were cancer and cancer-related deaths.

FINDINGS

We identified 70 randomised controlled trials (148 comparator groups) with 324,168 participants. In the network meta-analysis (fixed-effect model), we recorded no difference in the risk of cancer with ARBs (proportion with cancer 2·04%; odds ratio 1·01, 95% CI 0·93-1·09), ACEi (2·03%; 1·00, 0·92-1·09), β blockers (1·97%; 0·97, 0·88-1·07), CCBs (2·11%; 1·05, 0·96-1·13), diuretics (2·02%; 1·00, 0·90-1·11), or other controls (1·95%, 0·97, 0·74-1·24) versus placebo (2·02%). There was an increased risk with the combination of ACEi plus ARBs (2·30%, 1·14, 1·02-1·28); however, this risk was not apparent in the random-effects model (odds ratio 1·15, 95% CI 0·92-1·38). No differences were detected in cancer-related mortality for ARBs (death rate 1·33%; odds ratio 1·00, 95% CI 0·87-1·15), ACEi (1·25%; 0·95, 0·81-1·10), β blockers (1·23%; 0·93, 0·80-1·08), CCBs (1·27%; 0·96, 0·82-1·11), diuretics (1·30%; 0·98, 0·84-1·13), other controls (1·43%; 1·08, 0·78-1·46), and ACEi plus ARBs (1·45%; 1·10, 0·90-1·32). In direct comparison meta-analyses, similar results were recorded for all antihypertensive classes, except for an increased risk of cancer with ACEi and ARB combination (OR 1·14, 95% CI 1·04-1·24; p=0·004) and with CCBs (1·06, 1·01-1·12; p=0·02). However, we noted no significant differences in cancer-related mortality. On the basis of trial sequential analysis, our results suggest no evidence of even a 5-10% relative risk (RR) increase of cancer and cancer-related deaths with any individual class of antihypertensive drugs studied. However, for the ACEi and ARB combination, the cumulative Z curve crossed the trial sequential monitoring boundary, suggesting firm evidence for at least a 10% RR increase in cancer risk.

INTERPRETATION

Our analysis refutes a 5·0-10·0% relative increase in the risk of cancer or cancer-related death with the use of ARBs, ACEi, β blockers, diuretics, and CCBs. However, increased risk of cancer with the combination of ACEi and ARBs cannot be ruled out.

ACE inhibitors in cardiac surgery: current studies and controversies

Major complications associated with cardiac surgery are still common and carry great prognostic significance. Current medical interventions to prevent these cardiovascular complications include antiplatelet therapy, statins, β-blockers and angiotensin-converting enzyme (ACE) inhibitors. Both experimental studies and clinical trials have shown that ACE inhibitors hold promise as cardiovascular protective agents for cardiac surgery patients. Several lines of evidence support this hypothesis. First, long-term use of ACE inhibitors has been well established to provide cardiovascular protection and reduce ischemic events and complications, independent of their effect on heart function and blood pressure. Second, early ACE inhibitor therapy has been demonstrated to produce remarkable survival and heart function benefits in patients with acute myocardial infarction. Third, ACE blockage can prevent or delay the development or progression of renal disease at all stages, from subclinical microalbuminuria to end-stage renal disease. Nevertheless, perioperative studies of the effects of ACE inhibitors remain few and inconclusive. Results from recent clinical trials and observational studies are conflicting and raise more questions than answers. Further studies, both retrospective and larger-scale prospective studies, are critically needed to examine whether ACE inhibitors reduce mortality and major complications in patients undergoing cardiac surgery.

Preoperative renin-angiotensin system inhibitors protect renal function in aging patients undergoing cardiac surgery

BACKGROUND

Renal failure (RF) represents a major postoperative complication for elderly patients undergoing cardiac surgery. This observational cohort study examines effects of preoperative use of renin-angiotensin system (RAS) inhibitors on postoperative renal failure in aging patients undergoing cardiac surgery.

METHODS AND RESULTS

We retrospectively analyzed a cohort of 1287 patients who underwent cardiac surgery at this institution (2003-2007). The patients included were ≥65 years old, scheduled for elective cardiac surgery, and without preexisting RF (defined by the criteria of the Society of Thoracic Surgeons as described in Method). Of all patients evaluated, 346 patients met the inclusion criteria and were divided into two groups: using (n = 122) or not using (n = 224) preoperative RAS inhibitors. A comparison of the two groups showed no significant differences in baseline parameters, including creatinine clearance, body mass index, history of diabetes and smoking, preoperative medicines (except that more patients with RAS inhibitors had a history of hypertension or congestive heart failure, fewer RAS inhibitor patients had chronic lung disease), in intraoperative perfusion and aortic cross-clamp time, and in postoperative complications and 30-d mortality. Multivariate logistic regression analysis demonstrated, however, that preoperative RAS inhibitors significantly and independently reduced the incidence of postoperative RF in the patients undergoing cardiac surgery compared with those not taking RAS inhibitors: 1.6% versus 7.6%, yielding an odds ratio of 0.19 (95 % CI 0.04-0.84, P = 0.029).

CONCLUSIONS

Preoperative RAS inhibitors may have significant renoprotective effects for aging patients undergoing elective cardiac surgery.

Prior coronary artery bypass graft surgery patients undergoing diagnostic coronary angiography have multiple uncontrolled coronary artery disease risk factors and high risk for cardiovascular events

Limited contemporary data exist on the cardiovascular risk of patients with prior coronary artery bypass grafting surgery (CABG) requiring diagnostic coronary angiography. We examined the prevalence and control of coronary artery disease risk factors and the outcomes of 367 prior CABG patients who underwent diagnostic coronary angiography between October 1, 2004 and May 31, 2007 at the Dallas Veterans Affairs Medical Center. Mean age was 65 +/- 9 years, 97% were men, and the mean time from CABG to diagnostic angiography was 8.2 +/- 6.1 years. Hypertension, low-density lipoprotein cholesterol, diabetes mellitus, smoking, and obesity were suboptimally controlled in 70%, 59%, 47%, 33%, and 50%, respectively. Intake of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 88% and 81%, respectively. After a mean follow-up of 1.4 +/- 0.8 years, the incidence of death and major cardiovascular events was 10% and 32%, respectively. In spite of significant improvement compared to previous studies and good compliance with indicated medications, contemporary prior CABG patients undergoing coronary angiography still have multiple and poorly controlled coronary artery disease risk factors and high risk for cardiovascular events. Novel pharmacologic and behavioral treatment strategies are needed.

Inhibition of the renin-angiotensin-aldosterone system to prevent ischemic and atherothrombotic events

Blood pressure (BP) is a continuous risk factor for ischemic and atherosclerotic events such as stroke and ischemic heart disease, and controlling BP is a well-established component of any cardiovascular or cerebrovascular risk reduction regimen. In most patients, > or =2 medications with different mechanisms of action will be necessary to reach recommended BP goals. The neuroendocrine effects of the renin-angiotensin-aldosterone-system (RAAS) have proven to be excellent therapeutic targets for BP lowering. A number of antiatherosclerotic effects have been attributed to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in addition to their antihypertensive effects. Because they have complementary actions on the RAAS, combination therapy with these agents has become the focus of recent clinical trials. This review describes the clinical data assessing the efficacy of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers individually and in combination in reducing the risk of stroke and ischemic heart disease.

Beneficial effects of complement inhibition with soluble complement receptor 1 (TP10) during cardiac surgery: is there a gender difference?

BACKGROUND

TP10, a potent inhibitor of complement activation during cardiopulmonary bypass (CPB) has been shown to significantly reduce the incidence of death and myocardial infarction (MI) in high-risk male patients undergoing cardiac surgery. However, the effect of TP10 in females was undefined because of the limited number of females studied. To examine the possibility of a gender effect, this phase 2 multi-center trial was undertaken to determine whether TP10 would also limit ischemic damage in a larger sample size of high-risk females undergoing cardiac surgery on cardiopulmonary bypass (CPB).

METHODS AND RESULTS

This prospective, double-blind, placebo-controlled, multi-center trial involved 297 high-risk (urgent surgery, CABG + Valve, reoperations, ejection fraction <30%) female patients randomized to receive a 5 mg/kg dose of TP10 (n=150) or placebo (n=147) as a 30-minute intravenous infusion before surgery. The primary end point was the incidence of death or MI at 28 days after surgery. Complement activation was assessed by levels of CH50 and SC5b-9 during and after CPB. TP10 was well tolerated and there were no differences in the safety profiles of the 2 groups. Although TP10 effectively suppressed complement activation (at 2 hours after CPB CH50 (mean+SD % change from baseline) 50+/-17% placebo versus 4+/-14% TP10; P=0.0001; SC5b-9 (ng/mL) 917+/-1067 placebo versus 204+/-79 TP10; P=0.0001), there was no difference in the primary end point between the groups (17% placebo versus 21% TP10; P=0.2550).

CONCLUSIONS

The benefits of TP10 appear to be gender-related. and mechanisms other than complement activation may be responsible for myocardial injury in high-risk female patients during cardiac surgery on CPB.

Efficacy of perindopril in reducing risk of cardiac events in patients with revascularized coronary artery disease

BACKGROUND

The aim of the study was to assess the effect on cardiac events of adding perindopril 8 mg once daily to standard preventive therapy in the subgroup of EUROPA patients with previous revascularization and without previous myocardial infarction (MI).

METHODS

We conducted a subgroup analysis of the EUROPA study patients according to their revascularization and previous MI history. Among the 12,218 patients of EUROPA, we identified 6709 (54.9%) patients who had a previous revascularization. Approximately equal proportions had undergone percutaneous coronary intervention (3122) or coronary artery bypass grafting (3136). Of the revascularized patients, 3047 (24.9%) patients had not experienced a previous MI.

RESULTS

Out of the 6709 revascularized patients, 3340 were treated with perindopril and 3369 with placebo. Baseline characteristics were similar to the whole EUROPA population in terms of demographics, medical history, physical examination (heart rate, blood pressure), and medications at screening. The mean patient age was 60 years, and 85% were men. The relative risk reduction with perindopril 8 mg was 17.3% (95% CI 1.3%-30.8%, P = .035) for the composite primary end point of cardiovascular death, nonfatal MI, and resuscitated cardiac arrest and was 23% (95% CI 4.9%-37.6%, P = .015) for fatal and nonfatal MI. In the 3047 revascularized patients without a history of MI, perindopril was associated with a relative risk reduction of 31.7% for fatal and nonfatal MI (95% CI 4.4%-51.2%, P = .026).

CONCLUSION

Perindopril 8 mg daily is beneficial for primary and secondary prevention of cardiac events in patients with coronary artery disease without clinical evidence of heart failure including those with previous revascularization.

Outcomes Associated With the Use of Secondary Prevention Medications After Coronary Artery Bypass Graft Surgery

BACKGROUND

Secondary prevention medications are beneficial after acute coronary syndromes, but these benefits are less clear after coronary artery bypass graft surgery. We investigated whether greater use of secondary prevention medications after coronary artery bypass graft surgery is associated with improved clinical outcomes.

METHODS

Patients undergoing coronary artery bypass graft surgery in the PREVENT IV trial (n = 2970) were surveyed for use of antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents after hospital discharge and at 1 year. Patients were categorized based on their percentage use of indicated medications after hospital discharge. Cox modeling was used to determine the association between medication use categories and rates of death or myocardial infarction through 2 years after adjustment for clinical factors, the number of indicated medications, and treatment propensity.

RESULTS

Rates of use of antiplatelet agents and lipid-lowering agents were high at discharge and at 1 year, but use of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was suboptimal. There was a stepwise association between medication use at discharge and patient outcomes (p for trend = 0.014). Patients taking 50% or less of indicated medications at discharge had a significantly higher 2-year rate of death or myocardial infarction (8.0% versus 4.2%; adjusted hazard ratio, 1.69; 95% confidence interval, 1.12 to 2.55; p = 0.013) than those taking all indicated medications.

CONCLUSIONS

Greater use of indicated secondary prevention medications after coronary artery bypass graft surgery is associated with a lower 2-year rate of death or myocardial infarction. These data underscore the importance of appropriate secondary prevention measures to improve long-term clinical outcomes after coronary artery bypass graft surgery.

Cardioprotective Strategies to Improve Long-Term Outcomes Following Coronary Artery Bypass Surgery

BACKGROUND AND AIM

Cardioprotective strategies implemented to prevent ischemic events in patients at risk for cardiovascular disease have decreased morbidity and prolonged survival. In this review, we have used evidence-based medicine and number-needed-to-treat (NNT) analyses to determine which interventions are most beneficial in minimizing ischemic events and prolonging survival following coronary artery bypass graft (CABG) surgery.

METHODS

Therapeutic interventions available to minimize ischemic events in the post-CABG patient were analyzed using ACC/AHA Classifications and Level of Evidence Criteria. Based on these recommendations, NNT analyses were performed to determine the effectiveness of each intervention compared to the number of patients needed to be treated before a benefit was apparent.

RESULTS

The most beneficial intervention to improve mortality following CABG was the use of high tissue angiotensin-converting enzyme inhibitors, followed by statins and smoking cessation.

CONCLUSIONS

NNT analyses and evidence-based medicine recommendations provide surgeons with cardioprotective strategies to improve long-term outcomes following CABG surgery.

Application of Evidence-Based Medical Therapy Is Associated With Improved Outcomes After Percutaneous Coronary Intervention and Is a Valid Quality Indicator

OBJECTIVES

We sought to determine whether the prescription of evidence-based medications at discharge after successful percutaneous coronary intervention (PCI) can predict long-term clinical outcome.

BACKGROUND

The association of standard-of-care drug utilization and long-term mortality and morbidity after PCI is not well studied.

METHODS

We performed a retrospective cohort study of successful PCI procedures performed on 7,745 patients between March 1, 1998, and December 31, 2004. Discharge medications were analyzed, and a medication score (MEDS) was developed. A MEDS of 1 was assigned for each of the following medication classes: 1) antiplatelet, 2) lipid-lowering, 3) beta-blocker, and 4) angiotensin-converting enzyme (ACE) inhibitor. The outcomes measured were long-term death, myocardial infarction, and revascularization.

RESULTS

Patients with MEDS of 3 to 4 had higher-risk profiles based upon standard clinical and angiographic criteria. Despite this, at a median follow-up of 36 months, patients with a MEDS of 3 or 4 were at lower risk of death than those with a MEDS of 0 or 1 (8.9%, 7.5%, and 13% for MEDS of 4, 3, and 0 to 1, respectively; p = 0.014). After adjustment for covariates, a MEDS of 3 to 4 was associated with significantly lower mortality or myocardial infarction in follow-up than a MEDS of 0 to 1 (hazard ratios of 0.72 and 0.67 for MEDS of 3 and 4, respectively; p < 0.01). There was no association between MEDS and target vessel revascularization.

CONCLUSIONS

After successful PCI, the use of multiple evidence-based classes of cardiovascular medications--antiplatelet, lipid-lowering, beta-blockers, and ACE inhibitors--is associated with improved outcome free of death or MI.

The use of angiotensin-converting enzyme inhibitors in patients undergoing coronary artery bypass graft surgery

Angiotensin-converting enzyme inhibitors have been shown to prolong survival, decrease infarct size, and improve ventricular function in patients who have congestive heart failure, and in those who have sustained a myocardial infarction. This review will summarize the evidence to show that angiotensin-converting enzyme inhibitors can also benefit patients undergoing coronary artery bypass graft surgery by minimizing perioperative ischemia, and reducing long-term cardiovascular events.

Angiotensin Antagonism in Coronary Artery Disease

The renin-angiotensin system (RAS) is an ancient and complex cascade of homeostatic reactions aimed at regulating primordial functions that ensure organ perfusion through the control of blood pressure and the regulation of renal-cardiac activity. However, the over-expression or lack of compensatory mechanisms of any of its components may initiate detrimental effects that potentially lead to disease, a balance that makes the RAS a sequence with a labile physiological equilibrium and with a strong harm potential. These characteristics of the RAS in general, and of the angiotensin converting enzyme (ACE) in particular, make it not only an important complex for the regulation of blood pressure and neuropeptide metabolism, but also a fascinating subject of study from a biochemical, evolutionary and genetic point of view. Pharmacological interventions that influence the RAS by inhibiting the ACE or the angiotensin II type 1 receptor (AT1R) have demonstrated sustained efficacy in reducing the incidence of cardiovascular events and, consequently, vascular mortality in several clinical situations. ACE inhibitors and angiotensin II receptor antagonists (ARAs) reduce blood pressure and have cardio- and vasculoprotective effects. Anti-atherosclerotic effects have also been attributed to these drugs. For these reasons, it has been hypothesised that RAS inhibitors could also reduce the recurrence of ischaemic events after myocardial revascularisation procedures, namely coronary artery by-pass graft surgery (CABG) or percutaneous coronary interventions (PCI). Information available on the effect of ACE inhibitors and ARAs in patients with coronary artery disease (CAD) previously treated with revascularisation techniques indicates a substantial reduction of mortality and infarction in these patients. However, data regarding the progression of CAD, restenosis or reocclusion of vascular conduits of the coronary circulation after myocardial revascularisation are inconsistent. In most studies, the administration of ACE inhibitors neither improved the ischaemic threshold nor reduced the need for new revascularisation procedures. On the contrary, ACE inhibitors have been associated with higher restenosis rates after PCI in some retrospective series. Conversely, a single, exploratory randomised trial demonstrated that the selective AT1R antagonist valsartan significantly reduced stent restenosis after PCI. In patients undergoing CABG, ACE inhibitors did not reduce the risk of graft degeneration or occlusion. Studies that evaluated a possible anti-atherosclerotic effect of ACE inhibitors (including some large randomised trials) have generally been negative.

The clinical use of angiotensin-converting enzyme inhibitors

Through an integrative understanding of cardiovascular pathophysiologic characteristics at the multiorgan level, significant achievements in cardiovascular therapeutics have been achieved and enabled the rationale design and development of drugs such as the angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). In this article, we present a detailed review of the physiologic features of the renin-angiotensin-aldosterone system (RAAS), ACE inhibitors and ARB clinical pharmacologic characteristics, and specific diseases in which they are considered to be the standard of the care as supported by important clinical trial data. It is envisioned that an updated and detailed understanding of ACE inhibitors and ARBs will facilitate their successful use in the treatment of heart failure, myocardial infarction, hypertension, renal failure, and diabetic nephropathy.

Extended follow-up of patients randomly assigned in the Angiotensin-converting enzyme inhibition Post-Revascularization Study (APRES)

BACKGROUND

We hypothesized that the benefit from ramipril on cardiac events and on left ventricular end-systolic volume (ESVI) in the Angiotensin-converting enzyme inhibition Post-revascularization Study (APRES) randomized controlled trial (RCT) was associated with long-term improvement.

METHODS

For the 3.2 years after the end of the RCT, we obtained information from a national database regarding date and cause of death and hospitalization for the 159 enrolled patients.

RESULTS

Assignment to ramipril in the RCT resulted in a lower rate of cardiac death or hospitalization with heart failure up to the time of complete follow-up of all patients at 4.3 years (relative risk [RR], 0.28; P =.018) and up to 1.5 years after the end of the RCT (RR, 0.35; P =.042) but not up to the complete extended follow-up time at 6.9 years (RR, 0.65; P =.27). Independent predictors for risk of future cardiac death or hospitalization with heart failure were (a) left ventricular dilation (LVD) (RR, 2.84; P =.031), defined as an increase in ESVI greater than the reproducibility coefficient, and (b) composite event of acute myocardial infarction or development of heart failure or LVD (RR, 12.44; P <.001). Ramipril significantly reduced events (a) (P =.046) and (b) (P =.015) during the RCT.

CONCLUSIONS

There is congruence between the beneficial effect of ramipril on LVD, acute myocardial infarction, or heart failure and the prognostic importance of these factors and on cardiac death and hospitalization with heart failure. This observation supports and reinforces conclusions from previous APRES reports that ramipril benefits non-high-risk patients after revascularization.

Effect of ramipril on postrevascularization prevalence of angina and quality of life

BACKGROUND

The prevalence of angina after invasive revascularization is not negligible and impacts on quality of life. It has not been clarified whether potential anti-ischemic actions of angiotensin-converting enzyme inhibitors (1) may apply to non high-risk patients and (2) may reduce the prevalence of angina. We sought to test the hypothesis that ramipril, an angiotensin-converting enzyme inhibitor, may reduce the postrevascularization prevalence of angina pectoris and improve quality of life.

METHODS

In the Angiotensin-converting enzyme Post-Revascularization Study (APRES), 159 patients who underwent invasive revascularization for chronic angina and who had not had heart failure, acute myocardial infarction (AMI), or severe left ventricular dysfunction were randomized to receive 10 mg of ramipril or placebo. During the 12- to 46-month follow-up, the Specific Activity Scale class, exercise tests, and SF-36 quality of life scores were serially assessed.

RESULTS

The average prevalence of angina of Specific Activity Scale class II or worse was 26.6% in the ramipril group and 19.9% in the placebo group (p=0.16). The average prevalence of exercise-inducible ischemia was 30.8% in the ramipril group and 25.2% in the placebo group (p=0.39). There were no significant differences between the two treatment groups in the SF-36 quality of life scores or in the Duke treadmill score. Post-hoc power calculations revealed that the power to rule out a clinical significant benefit of ramipril on the prevalence of angina, quality of life, and Duke treadmill score was >90%.

CONCLUSIONS

These data do not suggest that ramipril reduces the prevalence of angina pectoris or improves quality of life after invasive revascularization in such patients

Preventing recurrent events long term after coronary artery bypass graft: suboptimal use of medications in a population study

BACKGROUND

There are few population-based data on long-term management of patients after coronary artery bypass graft (CABG), despite the high risk for future major vascular events among this group. We assessed the prevalence and correlates of pharmacotherapy for prevention of new cardiac events in a large population-based series.

METHODS

A postal survey was conducted of 2500 randomly selected survivors from a state population of patients 6 to 20 years after first CABG.

RESULTS

Response was 82% (n = 2061). Use of antiplatelet agents (80%) and statins (64%) declined as age increased. Other independent predictors of antiplatelet use included statin use (odds ratio [OR] 1.6, 95% CI 1.26-2.05) and recurrent angina (OR 1.6, CI 1.17-2.06). Current smokers were less likely to use aspirin (OR 0.59, CI 0.4-0.89). Statin use was associated with reported high cholesterol (OR 24.4, CI 8.4-32.4), management by a cardiologist (OR 2.3, CI 1.8-3.0), and the use of calcium channel-blockers. Patients reporting hypertension or heart failure, in addition to high cholesterol, were less likely to use statins. Angiotensin-converting enzyme inhibitors were the most commonly prescribed agents for management of hypertension (59%) and were more frequently used among patients with diabetes and those with symptoms of heart failure. Overall 42% of patients were on angiotensin-converting enzyme inhibitors and 36% on beta-blockers.

CONCLUSIONS

Gaps exist in the use of recommended medications after CABG. Lower anti-platelet and statin use was associated with older age, freedom from angina, comorbid heart failure or hypertension, and not regularly visiting a cardiologist. Patients who continue to smoke might be less likely to adhere to prescribed medications.