ACE Inhibition in Stable Coronary Artery Disease

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Abstract
The results of the Prevention of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Trial1 (Nov. 11 issue)1 are probably the product of an underpowered trial. Only 8290 of a planned 14,100 patients were enrolled, and the primary outcome was changed to include revascularization — an outcome that depends on practice styles and that is therefore potentially insensitive to treatment. Two other trials, the Heart Outcomes Prevention Evaluation Study (HOPE)2 and the European Trial of Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA),3 showed significant reductions in the spontaneous and major vascular outcomes. The benefits in HOPE were consistent in patients at low risk (annual rate of death from cardiovascular causes, myocardial infarction, or stroke, 2 percent; relative risk, 0.82; 95 percent confidence interval, 0.65 to 1.04), those at medium risk (annual rate, 3.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.67 to 0.97), and those at high risk (annual rate, 5 percent; relative risk, 0.76; 95 percent confidence interval, 0.66 to 0.88), in patients receiving lipid-lowering drugs (relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.93), and in those who underwent revascularization (relative risk, 0.85; 95 percent confidence interval, 0.72 to 1.01). A meta-analysis of the HOPE, PEACE, and EUROPA data shows significant reductions in mortality ( Table 1 ), reinfarction, and stroke (data not shown). This confirms the clear benefits of angiotensin-converting–enzyme (ACE) inhibitors in patients with vascular disease and no left ventricular dysfunction.