 
Low-risk Heart Patients May Not Benefit From ACE Inhibition
(Reuters Health) Patients with stable coronary artery disease and preserved left ventricular
function who are already on intensive standard therapy show no clinical benefit from additional
treatment with an angiotensin-converting-enzyme inhibitor, investigators report.
The findings were reported Sunday at the American Heart Association meeting in New Orleans,
and are being published in the November 11th issue of the New England Journal of Medicine.
Dr. Eugene Braunwald, at Harvard Medical School, Boston, and investigators in the Prevention
of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Trial randomly assigned 4158 patients
to receive trandolapril 2 to 4 mg/day, and 4132 to matching placebo. Fifty-five percent had had an MI
and 72% had previously undergone coronary revascularization.
Standard treatment included antiplatelet medication (90-91%), lipid-lowering drugs (70%), and
beta-blockers (60%). Other drugs that were used by some were calcium-channel blockers, diuretics,
digitalis, antiarrhythmic agents or anticoagulants.
The primary end point -- death from cardiovascular causes, nonfatal MI, or coronary revascularization
-- was reached by 22.5% in the placebo group and 21.9% in the trandolapril group (p = 0.43), after a
median follow-up of 4.8 years. This lack of clinical benefit was seen despite differential effects on blood
pressure, which declined by a mean of 4.4/3.6 mm Hg in the active treatment group and 1.4/2.4 mm Hg
in the placebo group.
Other trials have been shown to reduce atherosclerotic complications patients with vascular disease.
The PEACE trial investigators point out, however, that their study cohort received more intensive treatment
of coronary artery disease and more aggressive management of risk factors than had those in other trials.
In fact, the annualized mortality rate of 1.6% is similar to that of an age- and sex-matched general population.
Nevertheless, the investigators conclude, "physicians may still wish to consider ACE-inhibitor therapy
for any patient who does not clearly fit the profile of patients in this trial."
In an accompanying editorial, Dr. Bertram Pitt, from the University of Michigan School of Medicine in
Ann Arbor, points out that "it is premature to discard the use of effective ACE inhibitors for all patients who
have vascular disease without left ventricular systolic dysfunction."
He still advocates ACE inhibitors for patients "with uncontrolled cardiovascular risk factors, those with
recurrent symptoms, and those with evidence of ongoing vascular inflammation or plaque instability."
New Engl J Med 2004;351:2058-2068,2115-2117.
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