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ACE inhibitor-ARB combination 'has no benefit'

Adding an ACE inhibitor to patients with stable ischaemic heart disease whose ventricular function is good reduces the risk of death and heart attack, a systematic review has found.

But the evidence for angiotensin receptor blockers (ARBs) is less strong, and the combination of an ACE inhibitor and an ARB had no benefit over monotherapy and increases the risk of hypotension and syncope.

The researchers behind the review, from the University of Connecticut, looked at 41 trials with 32,559 trial participants, all with stable ischemic heart disease and preserved ventricular function.

Those who took ACE inhibitors had 87% the risk of mortality compared to placebo or active control, and 83% of the risk of non-fatal myocardial infarction. However those taking ACE inhibitors had a 24% increased risk of syncope.

The evidence was not as strong for ARBs and - although those taking them were less likely to die of a cardiovascular related cause, to have a non-fatal heart attack, or to have a stroke - the risk reduction was on the border of statistical significance (CI 0.77 to 1.00).

Those who took both types of drug were significantly more likely to stop treatment because of syncope and hypotension. ‘Combination therapy seems no better than ACE inhibitor therapy alone and increases harms' the authors conclude.

Annals of Internal Medicine 2009 151 (12) published online first October 20, 2009.

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