Background: Angiotensin-converting-enzyme(ACE) inhibitors reduce cardiovascular mortality and morbidity in patients with heart failure or left ventricular systolic dysfunction(LVSD). Three large trials have assessed t...Background: Angiotensin-converting-enzyme(ACE) inhibitors reduce cardiovascular mortality and morbidity in patients with heart failure or left ventricular systolic dysfunction(LVSD). Three large trials have assessed the effect of ACE inhibitors in stable patients without these conditions but with atherosclerosis. We undertook a systematic review of the Heart Outcomes Prevention Evaluation(HOPE), the European trial on Reduction Of cardiac events with Perindopril among patients with stable coronary Artery disease(EUROPA), and the Prevention of Events with ACE inhibition(PEACE) studies to determine the consistency with which ACE inhibitors reduce total mortality and fatal and non-fatal cardiovascular events. Methods: We computed cardiovascular outcomes and total mortality in the 29 805 patients of these three trials, randomly assigned an ACE inhibitor or placebo and followed up for a mean of about 4.5 years. The results were also analysed within the context of five large trials of ACE inhibitors in patients with heart failure or LVSD. Findings: When the findings of the HOPE, EUROPA, and PEACE trials were combined, ACE inhibitors significantly reduced all-cause mortality(7.8 vs 8.9%, p=0.0004), cardiovascular mortality(4.3 vs 5.2%, p=0.0002), nonfatal myocardial infarction(5.3 vs 6.4%, p=0.0001), all stroke(2.2 vs 2.8%, p=0.0004), heart failure(2.1 vs 2.7%, p=0.0007), coronary-artery bypass surgery(6.0 vs 6.9%, p=0.0036) but not percutaneous coronary intervention(7.4 vs 7.6%, p=0.481). The composite outcomes of cardiovascular mortality, non-fatal myocardial infarction, or stroke occurred in 1599(10.7%) of the patients allocated ACE inhibitor and in 1910(12.8%) of those allocated placebo(odds ratio, 0.82; 95%CIs 0.76-0.88; p<0.0001). Except for stroke and revascularisation, these results were similar to those of the five trials in patients with heart failure or LVSD. Interpretation: ACE inhibitors reduce serious vascular events in patients with atherosclerosis without known evidence of LVSD or heart failure. Results showing these benefits in intermediate-risk patients complement existing evidence of similar benefit in higher-risk patients with LVSD or heart failure. Therefore, use of ACE inhibitors should be considered in all patients with atherosclerosis.展开更多
Aims: To assess the screening characteristics and cost-effectiveness of screening for left ventricular systolic dysfunction(LVSD) in community subjects. Methods and results: A total of 1392 members of the general publ...Aims: To assess the screening characteristics and cost-effectiveness of screening for left ventricular systolic dysfunction(LVSD) in community subjects. Methods and results: A total of 1392 members of the general public and 928 higher risk subjects were randomly selected from seven community practices. Attending subjects underwent an ECG, N-terminal pro-brain natriuretic peptide(NTproBNP) serum levels, and traditional echocardiography(TE). A total of 533 consecutive subjects underwent hand-held echocardiography(HE). The screening characteristics and cost-effectiveness(cost per case of LVSD diagnosed) of eight strategies to predict LVSD(LVSD < 45% on TE) were compared. A total of 1205 subjects attended. Ninety six per cent of subjects with LVSD in the general population had identifiable risk factors. All screening strategies gave excellent negative predictive value. Screening high-risk subjects was most cost-effective, screening low-risk subjects least cost-effective. TE screening was the least cost-effective strategy. NTproBNP screening gave similar cost savings to ECG screening; HE screening greater cost-savings, and HE screening following NTproBNP or ECG pre-screening the greatest cost-savings, costing ～ 650 Euros per case of LVSD diagnosed in high-risk subjects(63% cost-savings vs. TE). Conclusion: Thus several different modalities allow cost-effective community-based screening for LVSD, especially in high-risk subjects. Such programmes would be cost-effective and miss few cases of LVSD in the community.展开更多
文摘Background: Angiotensin-converting-enzyme(ACE) inhibitors reduce cardiovascular mortality and morbidity in patients with heart failure or left ventricular systolic dysfunction(LVSD). Three large trials have assessed the effect of ACE inhibitors in stable patients without these conditions but with atherosclerosis. We undertook a systematic review of the Heart Outcomes Prevention Evaluation(HOPE), the European trial on Reduction Of cardiac events with Perindopril among patients with stable coronary Artery disease(EUROPA), and the Prevention of Events with ACE inhibition(PEACE) studies to determine the consistency with which ACE inhibitors reduce total mortality and fatal and non-fatal cardiovascular events. Methods: We computed cardiovascular outcomes and total mortality in the 29 805 patients of these three trials, randomly assigned an ACE inhibitor or placebo and followed up for a mean of about 4.5 years. The results were also analysed within the context of five large trials of ACE inhibitors in patients with heart failure or LVSD. Findings: When the findings of the HOPE, EUROPA, and PEACE trials were combined, ACE inhibitors significantly reduced all-cause mortality(7.8 vs 8.9%, p=0.0004), cardiovascular mortality(4.3 vs 5.2%, p=0.0002), nonfatal myocardial infarction(5.3 vs 6.4%, p=0.0001), all stroke(2.2 vs 2.8%, p=0.0004), heart failure(2.1 vs 2.7%, p=0.0007), coronary-artery bypass surgery(6.0 vs 6.9%, p=0.0036) but not percutaneous coronary intervention(7.4 vs 7.6%, p=0.481). The composite outcomes of cardiovascular mortality, non-fatal myocardial infarction, or stroke occurred in 1599(10.7%) of the patients allocated ACE inhibitor and in 1910(12.8%) of those allocated placebo(odds ratio, 0.82; 95%CIs 0.76-0.88; p<0.0001). Except for stroke and revascularisation, these results were similar to those of the five trials in patients with heart failure or LVSD. Interpretation: ACE inhibitors reduce serious vascular events in patients with atherosclerosis without known evidence of LVSD or heart failure. Results showing these benefits in intermediate-risk patients complement existing evidence of similar benefit in higher-risk patients with LVSD or heart failure. Therefore, use of ACE inhibitors should be considered in all patients with atherosclerosis.
文摘Aims: To assess the screening characteristics and cost-effectiveness of screening for left ventricular systolic dysfunction(LVSD) in community subjects. Methods and results: A total of 1392 members of the general public and 928 higher risk subjects were randomly selected from seven community practices. Attending subjects underwent an ECG, N-terminal pro-brain natriuretic peptide(NTproBNP) serum levels, and traditional echocardiography(TE). A total of 533 consecutive subjects underwent hand-held echocardiography(HE). The screening characteristics and cost-effectiveness(cost per case of LVSD diagnosed) of eight strategies to predict LVSD(LVSD < 45% on TE) were compared. A total of 1205 subjects attended. Ninety six per cent of subjects with LVSD in the general population had identifiable risk factors. All screening strategies gave excellent negative predictive value. Screening high-risk subjects was most cost-effective, screening low-risk subjects least cost-effective. TE screening was the least cost-effective strategy. NTproBNP screening gave similar cost savings to ECG screening; HE screening greater cost-savings, and HE screening following NTproBNP or ECG pre-screening the greatest cost-savings, costing ～ 650 Euros per case of LVSD diagnosed in high-risk subjects(63% cost-savings vs. TE). Conclusion: Thus several different modalities allow cost-effective community-based screening for LVSD, especially in high-risk subjects. Such programmes would be cost-effective and miss few cases of LVSD in the community.
