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James M Wright - One of the best experts on this subject based on the ideXlab platform.
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angiotensin converting enzyme ACE Inhibitors versus angiotensin receptor blockers for primary hypertension
Cochrane Database of Systematic Reviews, 2014Co-Authors: Balraj S Heran, James M WrightAbstract:Background Angiotensin converting enzyme Inhibitors (ACE Inhibitors) and angiotensin receptor blockers (ARBs) are widely prescribed for primary hypertension (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg). However, while ACE Inhibitors have been shown to reduce mortality and morbidity in plACEbo-controlled trials, ARBs have not. Therefore, a comparison of the efficacies of these two drug classes in primary hypertension for preventing total mortality and cardiovascular events is important. Objectives To compare the effects of ACE Inhibitors and ARBs on total mortality and cardiovascular events, and their rates of withdrawals due to adverse effects (WDAEs), in people with primary hypertension. Search methods We searched the Cochrane Hypertension Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the World Health Organization (WHO) International Clinical Trials Registry Platform, and the ISI Web of Science up to July 2014. We contacted study authors for missing and unpublished information, and also searched the reference lists of relevant reviews for eligible studies. Selection criteria We included randomized controlled trials enrolling people with uncontrolled or controlled primary hypertension with or without other risk factors. Included trials must have compared an ACE inhibitor and an ARB in a head-to-head manner, and lasted for a duration of at least one year. If background blood pressure lowering agents were continued or added during the study, the protocol to do so must have been the same in both study arms. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results Nine studies with 11,007 participants were included. Of the included studies, five reported data on total mortality, three reported data on total cardiovascular events, and four reported data on cardiovascular mortality. No study separately reported cardiovascular morbidity. In contrast, eight studies contributed data on WDAE. Included studies were of good to moderate quality. There was no evidence of a difference between ACE Inhibitors and ARBs for total mortality (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.88 to 1.10), total cardiovascular events (RR 1.07; 95% CI 0.96 to 1.19), or cardiovascular mortality (RR 0.98; 95% CI 0.85 to 1.13). Conversely, a high level of evidence indicated a slightly lower incidence of WDAE for ARBs as compared with ACE Inhibitors (RR 0.83; 95% CI 0.74 to 0.93; absolute risk reduction (ARR) 1.8%, number needed to treat for an additional beneficial outcome (NNTB) 55 over 4.1 years), mainly attributable to a higher incidence of dry cough with ACE Inhibitors. The quality of the evidence for mortality and cardiovascular outcomes was limited by possible publication bias, in that several studies were initially eligible for inclusion in this review, but had no extractable data available for the hypertension subgroup. To this end, the evidence for total mortality was judged to be moderate, while the evidence for total cardiovascular events was judged to be low by the GRADE approach. Authors' conclusions Our analyses found no evidence of a difference in total mortality or cardiovascular outcomes for ARBs as compared with ACE Inhibitors, while ARBs caused slightly fewer WDAEs than ACE Inhibitors. Although ACE Inhibitors have shown efficacy in these outcomes over plACEbo, our results cannot be used to extrapolate the same conclusion for ARBs directly, which have not been studied in plACEbo-controlled trials for hypertension. Thus, the substitution of an ARB for an ACE inhibitor, while supported by evidence on grounds of tolerability, must be made in consideration of the weaker evidence for the efficacy of ARBs regarding mortality and morbidity outcomes compared with ACE Inhibitors. Additionally, our data mostly derives from participants with existing clinical sequelae of hypertension, and it would be useful to have data from asymptomatic people to increase the generalizability of this review. Unpublished subgroup data of hypertensive participants in existing trials comparing ACE Inhibitors and ARBs needs to be made available for this purpose.
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blood pressure lowering efficacy of angiotensin converting enzyme ACE Inhibitors for primary hypertension
Cochrane Database of Systematic Reviews, 2008Co-Authors: Balraj S Heran, Michelle My Wong, Inderjit K Heran, James M WrightAbstract:Background ACE Inhibitors are widely prescribed for hypertension so it is essential to determine and compare their effects on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAE). Objectives To quantify the dose-related systolic and/or diastolic BP lowering efficacy of ACE Inhibitors versus plACEbo in the treatment of primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007), EMBASE (1988 to February 2007) and reference lists of articles. Selection criteria Double-blind, randomized, controlled trials evaluating the BP lowering efficacy of fixed-dose monotherapy with an ACE inhibitor compared with plACEbo for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was collected from the trials. Main results Ninety two trials evaluated the dose-related trough BP lowering efficacy of 14 different ACE Inhibitors in 12 954 participants with a baseline BP of 157/101 mm Hg. The data do not suggest that any one ACE inhibitor is better or worse at lowering BP. A dose of 1/8 or 1/4 of the manufacturer's maximum recommended daily dose (Max) achieved a BP lowering effect that was 60 to 70% of the BP lowering effect of Max. A dose of 1/2 Max achieved a BP lowering effect that was 90% of Max. ACE inhibitor doses above Max did not significantly lower BP more than Max. Combining the effects of 1/2 Max and higher doses gives an estimate of the average trough BP lowering efficacy for ACE Inhibitors as a class of drugs of -8 mm Hg for SBP and -5 mm Hg for DBP. ACE Inhibitors reduced BP measured 1 to 12 hours after the dose by about 11/6 mm Hg. Authors' conclusions There are no clinically meaningful BP lowering differences between different ACE Inhibitors. The BP lowering effect of ACE Inhibitors is modest; the magnitude of trough BP lowering at one-half the manufacturers' maximum recommended dose and above is -8/-5 mm Hg. Furthermore, 60 to 70% of this trough BP lowering effect occurs with recommended starting doses. The review did not provide a good estimate of the incidence of harms associated with ACE Inhibitors because of the short duration of the trials and the lack of reporting of adverse effects in many of the trials.
Wayne A Ray - One of the best experts on this subject based on the ideXlab platform.
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major congenital malformations after first trimester exposure to ACE Inhibitors
Obstetrical & Gynecological Survey, 2006Co-Authors: William O Cooper, Sonia Hernandezdiaz, Patrick G Arbogast, Judith A Dudley, Shannon M Dyer, Patricia Gideon, Kathi Hall, Wayne A RayAbstract:ABSTRACT Although angiotensin-converting enzyme (ACE) Inhibitors are avoided in the second and third trimesters of pregnancy because of an increased risk of fetal pathology, adverse fetal outcomes have not been related to first-trimester exposure. For the most part, however, evidence that exposure early in pregnancy is safe comes from a limited number of animal studies and case report analyses. This cohort study included 29,507 infants enrolled in Medicaid in Tennessee who were born in the years 1985 to 2000 and for whom there was no evidence of maternal diabetes. A total of 411 infants had been exposed to some kind of antihypertensive medication only in the first trimester: 209 infants had been exposed to ACE Inhibitors and 202 were exposed to other antihypertensive drugs. Among the 202 infants exposed to other antihypertensive agents in the first trimester, the risk of any major congenital malformation was not increased. Of the 209 infants exposed to ACE Inhibitors in the first trimester, 18 had major congenital malformations (8.6%); the adjusted proportion was 7.1%. Seven of these 18 infants had multiple malformations, but 5 of the 7 had been exposed in the second trimester as well and 3 had been exposed in all 3 trimesters. The risk ratio (RR) for first-trimester exposure, compared with children not exposed to any type of antihypertensive drug, was 2.71 (95% confidence interval [CI], 1.72–4.27). This RR was the result of an increased number of cardiovascular malformations (n = 8; RR, 3.72; 95% CI, 1.89–7.30) and central nervous system malformations (n = 3; RR, 4.39; 95% CI, 1.37–14.02). Other malformations included renal dysplasia (n = 2), hypospadius, intestinal and choanal atresia, Hirschsprung disease, and diaphragmatic hernia (n = 1 each). A post hoc analysis revealed a significantly increased risk of renal malformations (RR, 9.32; 95% CI, 1.79–48.5), but the risk of the other malformations was not significantly increased. Women of childbearing age, like other individuals, are increasingly being given ACE Inhibitors as the indications for these drugs continue to expand. The present findings strongly suggest that these drugs should not be given to pregnant women during the first trimester.
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major congenital malformations after first trimester exposure to ACE Inhibitors
The New England Journal of Medicine, 2006Co-Authors: William O Cooper, Sonia Hernandezdiaz, Patrick G Arbogast, Judith A Dudley, Shannon M Dyer, Patricia Gideon, Kathi Hall, Wayne A RayAbstract:Background Use of angiotensin-converting–enzyme (ACE) Inhibitors during the second and third trimesters of pregnancy is contraindicated because of their association with an increased risk of fetopathy. In contrast, first-trimester use of ACE Inhibitors has not been linked to adverse fetal outcomes. We conducted a study to assess the association between exposure to ACE Inhibitors during the first trimester of pregnancy only and the risk of congenital malformations. Methods We studied a cohort of 29,507 infants enrolled in Tennessee Medicaid and born between 1985 and 2000 for whom there was no evidence of maternal diabetes. We identified 209 infants with exposure to ACE Inhibitors in the first trimester alone, 202 infants with exposure to other antihypertensive medications in the first trimester alone, and 29,096 infants with no exposure to antihypertensive drugs at any time during gestation. Major congenital malformations were identified from linked vital records and hospitalization claims during the first year of life and confirmed by review of medical records. Results
Balraj S Heran - One of the best experts on this subject based on the ideXlab platform.
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angiotensin converting enzyme ACE Inhibitors versus angiotensin receptor blockers for primary hypertension
Cochrane Database of Systematic Reviews, 2014Co-Authors: Balraj S Heran, James M WrightAbstract:Background Angiotensin converting enzyme Inhibitors (ACE Inhibitors) and angiotensin receptor blockers (ARBs) are widely prescribed for primary hypertension (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg). However, while ACE Inhibitors have been shown to reduce mortality and morbidity in plACEbo-controlled trials, ARBs have not. Therefore, a comparison of the efficacies of these two drug classes in primary hypertension for preventing total mortality and cardiovascular events is important. Objectives To compare the effects of ACE Inhibitors and ARBs on total mortality and cardiovascular events, and their rates of withdrawals due to adverse effects (WDAEs), in people with primary hypertension. Search methods We searched the Cochrane Hypertension Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the World Health Organization (WHO) International Clinical Trials Registry Platform, and the ISI Web of Science up to July 2014. We contacted study authors for missing and unpublished information, and also searched the reference lists of relevant reviews for eligible studies. Selection criteria We included randomized controlled trials enrolling people with uncontrolled or controlled primary hypertension with or without other risk factors. Included trials must have compared an ACE inhibitor and an ARB in a head-to-head manner, and lasted for a duration of at least one year. If background blood pressure lowering agents were continued or added during the study, the protocol to do so must have been the same in both study arms. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results Nine studies with 11,007 participants were included. Of the included studies, five reported data on total mortality, three reported data on total cardiovascular events, and four reported data on cardiovascular mortality. No study separately reported cardiovascular morbidity. In contrast, eight studies contributed data on WDAE. Included studies were of good to moderate quality. There was no evidence of a difference between ACE Inhibitors and ARBs for total mortality (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.88 to 1.10), total cardiovascular events (RR 1.07; 95% CI 0.96 to 1.19), or cardiovascular mortality (RR 0.98; 95% CI 0.85 to 1.13). Conversely, a high level of evidence indicated a slightly lower incidence of WDAE for ARBs as compared with ACE Inhibitors (RR 0.83; 95% CI 0.74 to 0.93; absolute risk reduction (ARR) 1.8%, number needed to treat for an additional beneficial outcome (NNTB) 55 over 4.1 years), mainly attributable to a higher incidence of dry cough with ACE Inhibitors. The quality of the evidence for mortality and cardiovascular outcomes was limited by possible publication bias, in that several studies were initially eligible for inclusion in this review, but had no extractable data available for the hypertension subgroup. To this end, the evidence for total mortality was judged to be moderate, while the evidence for total cardiovascular events was judged to be low by the GRADE approach. Authors' conclusions Our analyses found no evidence of a difference in total mortality or cardiovascular outcomes for ARBs as compared with ACE Inhibitors, while ARBs caused slightly fewer WDAEs than ACE Inhibitors. Although ACE Inhibitors have shown efficacy in these outcomes over plACEbo, our results cannot be used to extrapolate the same conclusion for ARBs directly, which have not been studied in plACEbo-controlled trials for hypertension. Thus, the substitution of an ARB for an ACE inhibitor, while supported by evidence on grounds of tolerability, must be made in consideration of the weaker evidence for the efficacy of ARBs regarding mortality and morbidity outcomes compared with ACE Inhibitors. Additionally, our data mostly derives from participants with existing clinical sequelae of hypertension, and it would be useful to have data from asymptomatic people to increase the generalizability of this review. Unpublished subgroup data of hypertensive participants in existing trials comparing ACE Inhibitors and ARBs needs to be made available for this purpose.
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blood pressure lowering efficacy of angiotensin converting enzyme ACE Inhibitors for primary hypertension
Cochrane Database of Systematic Reviews, 2008Co-Authors: Balraj S Heran, Michelle My Wong, Inderjit K Heran, James M WrightAbstract:Background ACE Inhibitors are widely prescribed for hypertension so it is essential to determine and compare their effects on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAE). Objectives To quantify the dose-related systolic and/or diastolic BP lowering efficacy of ACE Inhibitors versus plACEbo in the treatment of primary hypertension. Search methods We searched CENTRAL (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007), EMBASE (1988 to February 2007) and reference lists of articles. Selection criteria Double-blind, randomized, controlled trials evaluating the BP lowering efficacy of fixed-dose monotherapy with an ACE inhibitor compared with plACEbo for a duration of 3 to 12 weeks in patients with primary hypertension. Data collection and analysis Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was collected from the trials. Main results Ninety two trials evaluated the dose-related trough BP lowering efficacy of 14 different ACE Inhibitors in 12 954 participants with a baseline BP of 157/101 mm Hg. The data do not suggest that any one ACE inhibitor is better or worse at lowering BP. A dose of 1/8 or 1/4 of the manufacturer's maximum recommended daily dose (Max) achieved a BP lowering effect that was 60 to 70% of the BP lowering effect of Max. A dose of 1/2 Max achieved a BP lowering effect that was 90% of Max. ACE inhibitor doses above Max did not significantly lower BP more than Max. Combining the effects of 1/2 Max and higher doses gives an estimate of the average trough BP lowering efficacy for ACE Inhibitors as a class of drugs of -8 mm Hg for SBP and -5 mm Hg for DBP. ACE Inhibitors reduced BP measured 1 to 12 hours after the dose by about 11/6 mm Hg. Authors' conclusions There are no clinically meaningful BP lowering differences between different ACE Inhibitors. The BP lowering effect of ACE Inhibitors is modest; the magnitude of trough BP lowering at one-half the manufacturers' maximum recommended dose and above is -8/-5 mm Hg. Furthermore, 60 to 70% of this trough BP lowering effect occurs with recommended starting doses. The review did not provide a good estimate of the incidence of harms associated with ACE Inhibitors because of the short duration of the trials and the lack of reporting of adverse effects in many of the trials.
H Sasaki - One of the best experts on this subject based on the ideXlab platform.
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ACE Inhibitors and protection against pneumonia in elderly patients with stroke
Neurology, 2005Co-Authors: T Arai, Kiyohisa Sekizawa, Takashi Ohrui, Hisayoshi Fujiwara, N Yoshimi, H Matsuoka, H SasakiAbstract:Pneumonia is the most common cause of death from nosocomial infection in the elderly. The increased incidence of pneumonia and the high mortality are consequences of a number of age-related factors, including coexisting illnesses, therapeutic interventions, and the aging process itself.1 Pneumonia has been estimated to occur in about one third of patients with stroke.2 The most important factor contributing to the risk of pneumonia in patients with stroke is suggested to be dysphagia with aspiration.1 Angiotensin-converting enzyme (ACE) Inhibitors have been shown to improve silent aspiration3 and prevent pneumonia in elderly patients with stroke.4 However, little is known about whether ACE Inhibitors have a beneficial role in reducing the risk of pneumonia as compared to other classes of antihypertensive drugs in elderly patients with stroke. Thus, we investigated whether ACE Inhibitors can reduce the risk of pneumonia …
Young Kwang Chae - One of the best experts on this subject based on the ideXlab platform.
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reduced risk of breast cancer recurrence in patients using ACE Inhibitors arbs and or statins
Cancer Investigation, 2011Co-Authors: Young Kwang Chae, Matias E Valsecchi, Jongoh Kim, Anabella Lucca Bianchi, Danai Khemasuwan, Ajit DesaiAbstract:Background: Epidemiologic and biochemical evidence suggest a role of statins and angiotensin-converting enzyme (ACE) Inhibitors or angiotensin-receptor blockers (ARBs) as anti-neoplastic agents. This study was designed to evaluate the association between the use of these agents and the risk of breast cancer recurrence. Methods: We reviewed the medical records of patients treated for stage II/III breast cancer between 1999 and 2005. Statin and ACE-Inhibitors/ARB users were defined as patients who took these medications for at least 6 months in no evidence of disease (NED) stage after the initial diagnosis. The primary outcome was disease-free survival and the secondary was overall survival. The Kaplan–Meier and Cox proportional hazard models were used. Results: A total of 703 patients were included. The median and maximal of follow up was 55 and 118 months, respectively. A total of 168 patients used ACE-Inhibitors/ARBs, 156 patients used statins, and 81 used both. Univariate analysis showed significant red...