Angiotensin inhibition after myocardial infarction: Does drug class matter? Authors
Received: 30 December 2005 Revised: 10 February 2006 Accepted: 22 June 2006 DOI:
Cite this article as: Winkelmayer, W.C., Fischer, M.A., Schneeweiss, S. et al. J GEN INTERN MED (2006) 21: 1242. doi:10.1111/j.1525-1497.2006.00590.x Abstract Angiotensin converting enzyme-inhibitors (ACEI) and angiotensin-II-receptor blockers (ARB) are equally efficacious in reducing mortality after MI, although the latter are far more costly. Little is known about their relative use after MI in typical care settings, and about their relative effectiveness outside the clinical trial setting. BACKGROUND: To assess temporal trends in the relative use of ACEI and ARB after myocardial infarction, and to test for differences in 1-year survival between users of these drug classes. OBJECTIVES: Retrospective closed cohort study. DESIGN: Medicare beneficiaries who survived >90 days after myocardial infarction, had full prescription drug coverage, and who filled a prescription for either ACEI or ARB within 90 days of myocardial infarction. PATIENTS: Relative use of ACEI versus ARB over time. Adjusted relative 1-year mortality between ACEI and ARB users. MEASUREMENTS: Between 1995 and 2004, 14,190 patients met inclusion criteria. Mean age was 80 years, 75% were female, and 90% were white. Overall, 88% received an ACEI, and 12% an ARB, with the proportion receiving an ARB increasing from 2% (1995) to 25% (2004; RESULTS: P<.001). Multivariate-adjusted 1-year mortality did not differ between ARB and ACEI users (HR: 1.04; 95% confidence interval: 0.88 to 1.22). The findings were similar for new users of ACEI/ARB, and for those with preexisting heart failure. ARB users had the same 1-year mortality after myocardial infarction as ACEI users in routine care. Use of more costly ARB has increased dramatically over time, to a quarter of ACEI/ARB users, despite the lack of a therapeutic advantage for most patients. CONCLUSIONS: Key words Coronary heart disease epidemiology health services and outcomes research preventive cardiology
Dr. Winkelmayer is supported by an American Heart Association Scientist Development Grant (AHA 0535232N). He is also a 2004 to 2006 T. Franklin Williams Scholar in Geriatric Nephrology (American Society of Nephrology-Association of Subspecialty Professors Junior Development Award in Geriatric Nephrology, jointly sponsored by the Atlantic Philanthropies, the American Society of Nephrology, the John A. Hartford Foundation, and the Association of Subspecialty Professors).
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Pfeffer MA, Braunwald E, Moye LA, et al.
Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327:669–77.
Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The acute infarction ramipril efficacy (AIRE) study investigators. Lancet. 1993;342:821–8.
Kober L, Torp-Pedersen C, Carlsen JE, et al.
A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril cardiac evaluation (TRACE) study group. N Engl J Med. 1995;333:1670–6.
Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICROHOPE substudy. Heart outcomes prevention evaluation study investigators. Lancet. 2000;355:253–9.
Israili ZH, Hall WD
. Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. A review of the literature and pathophysiology. Ann Intern Med. 1992;117:234–42.
McMurray JJ, McGuire A, Davie AP, Hughes D
. Cost-effectiveness of different ACE inhibitor treatment scenarios post-myocardial infarction. Eur Heart J. 1997;18:1411–5.
Golan L, Birkmeyer JD, Welch HG
. The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors. Ann Intern Med. 1999;131:660–7.
Weintraub WS, Cole J, Tooley JF
. Cost and cost-effectiveness studies in heart failure research. Am Heart J. 2002;143:565–76.
Rosen AB, Hamel MB, Weinstein MC, Cutler DM, Fendrick AM, Vijan S
. Cost-effectiveness of full medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes. Ann Intern Med. 2005;143:89–99.
Grossman E, Messerli FH, Neutel JM
. Angiotensin II receptor blockers: equal or preferred substitutes for ACE inhibitors? Arch Intern Med. 2000;160:1905–11.
Granger CB, McMurray JJ, Yusuf S, et al.
Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial [see comment]. Lancet. 2003;362:772–6.
Ramsay LE, Yeo WW
. ACE inhibitors, angiotensin II antagonists and cough. The Losartan cough study group. J Hum Hypertens. 1995;9(suppl. 5):S51-S54.
www.drugstore.com. Accessed June 23, 2005.
Pfeffer MA, McMurray JJ, Velazquez EJ, et al.
Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349:1893–906.
Dickstein K, Kjekshus J
. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal trial in myocardial infarction with angiotensin II antagonist losartan. Lancet. 2002;360:752–60.
Kiyota Y, Schneeweiss S, Glynn RJ, Cannuscio CC, Avorn J, Solomon DH
. Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records. Am Heart J. 2004;148:99–104.
Schneeweiss S, Avorn J
. A review of uses of health care utilization databases for epidemiologic research on therapeutics. J Clin Epidemiol. 2005;58:323–37.
. Angiotensin II receptor antagonists for the treatment of heart failure: what is their place after ELITE-II and Val-HeFT? J Renin Angiotensin Aldosterone Syst. 2001;2:89–92.
Morimoto T, Gandhi TK, Fiskio JM, et al.
Development and validation of a clinical prediction rule for angiotensin-converting enzyme inhibitor-induced cough. J Gen Intern Med. 2004;19:684–91.
Fischer MA, Schneeweiss S, Avorn J, Solomon DH
. Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors. N Engl J Med. 2004;351:2187–94.
Fischer MA, Choudhry NK, Winkelmayer WC. Impact of Medicaid prior authorization policies on use of angiotensin receptor blockers [Abstract]. J Gen Intern Med. 2006;21:S70.
McDonald MA, Simpson SH, Ezekowitz JA, Gyenes G, Tsuyuki RT
. Angiotensin receptor blockers and risk of myocardial infarction: systematic review. BMJ. 2005;331:873.
Lee VC, Rhew DC, Dylan M, Badamgarav E, Braunstein GD, Weingarten SR
. Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med. 2004;141:693–704.
Epstein BJ, Gums JG
. Angiotensin receptor blockers versus ACE inhibitors: prevention of death and myocardial infarction in high-risk populations. Ann Pharmacother. 2005;39:470–80.
Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E
. Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect? Ann Intern Med. 2004;141:102–12.
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