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ACE inhibitors cut risk at normal blood pressure

ACE inhibitors and ARBs prevent heart attacks, strokes and deaths in patients with a high risk of cardiovascular disease even if their blood pressure is normal, a new study concludes.

The large meta-analysis found an 11% reduction in cardiovascular events and death in patients who either had atheroscelorosis or were at high risk of it regardless of their systolic blood pressure.

In patients with a baseline systolic reading of less than 130mmHg that risk was cut by 16% while all-cause mortality fell by 11%, according to the analysis of data from 80,594 patients across 13 trials, published online by the European Heart Journal.

Study leader Dr Finlay McAlister, professor of medicine at the University of Alberta in Canada, said the findings supported calls to base prescribing decisions on individual cardiovascular risk rather than blood pressure measurement, adding: ‘The benefit was consistent across all the subgroups examined including those without systolic heart failure.’

Dr Terry McCormack, a GP in Whitby and council member of the Primary Care Cardiovascular Society, said smaller studies had shown people who were not hypertensive but at high risk of disease benefited from ACE inhibitors and ARBs, but there had been some debate about the effect. ‘It opens up the idea that if you had a polypill there probably should be an ACE inhibitor in there.’

Professor Morris Brown, professor of clinical pharmacology at the University of Cambridge and member of the British Hypertension Society guidelines and information service working party, said the finding underpinned concern some experts had about the NICE hypertension guidance based on ‘untested’ thresholds for ambulatory blood pressure.

‘Most strokes and MIs occur at levels of blood pressure which we do not currently treat. This meta-analysis will help to encourage a re-evaluation and with anti-hypertensive medication now costing about £1 per month, it is potentially a highly cost-effective way of reducing serious morbidity and mortality.’

Professor Bryan Williams, professor of medicine at the University of Leicester, said: ‘It is likely that the findings do reflect the reality, that is, if you are high risk, then on average, further reducing risk factors will further reduce risk. The polypill studies that are ongoing are evaluating this concept.’