Aims: It is unclear whether angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) are beneficial in individuals with, or at increased risk for, atherosclerotic vascular disease who are normotensive.
Methods and results: Two investigators independently searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1980 to 2011, bibliographies, and contacted primary study authors for randomized placebo-controlled outcome trials evaluating ACE-I or ARB which enrolled at least 1000 patients with, or at increased risk for, atherosclerotic vascular disease and followed them for at least 12 months. We approached all eligible trials to obtain data stratified by baseline systolic pressures. We pooled data from 13 trials of 80 594 patients; outcomes included 9043 all-cause deaths, 5674 cardiovascular deaths, 3106 myocardial infarctions, and 4452 strokes. Angiotensin-converting enzyme inhibitors or ARB reduced the composite primary outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke by 11% (95% confidence interval 7-15%), with no variation in efficacy across baseline systolic blood pressure strata. In patients with baseline systolic pressure <130 mmHg, ACE-I or ARB reduced the composite primary outcome by 16% (10-23%) and all-cause mortality by 11% (4-18%)-this benefit was consistent across all subgroups examined including those without systolic heart failure (OR: 0.81, 95% CI: 0.75-0.88) and those without diabetes (OR: 0.79, 95% CI: 0.70-0.89).
Conclusion: Angiotensin-converting enzyme inhibitors or ARB are beneficial in patients with, or at increased risk for, atherosclerotic disease even if their systolic pressure is <130 mmHg before treatment.