Overview of randomised trials of ACE inhibitors.

摘要

We fully agree with Giuseppe Remuzzi and Piero Ruggenenti (Aug 12, p 555)1 that there is a direct relation between the global cardiovascular risk and the cardiovascular benefit given by angiotensin-converting-enzyme (ACE) inhibitors in placebo-controlled trials, and that it is not a pure blood-pressure-dependent effect.When compared with other active drugs (that decrease blood pressure slightly more), their benefit is quite heterogeneous and organ-specific:2 when compared with calcium-antagonists, ACE inhibitors have a benefit in heart failure (relative risk 0-82, 95% CI 0-73-0-92) but it is the reverse for stroke prevention (1-12, 1-01-1-25). When compared with thiazide, they have no advantage for heart failure and a lower protective effect for stroke (1-09,1-00-1-18).For end-stage renal disease (ESRD), when all studies in the Casas meta-analysis3 are considered, ACE inhibitors and angiotensin-receptor blockers significantly decrease its risk. However this decrease is not significantly greater in diabetic than in non-diabetic patients, whereas patients with diabetes are presumably at higher cardiovascular risk. This finding could be caused by the ALLHAT study in which the large (n=5944) subgroup of diabetic patients with baseline glomerular filtration rate of 60-89 mL/min had a 74% increased risk of ESRD with lisinopril compared with thiazide.4The lower rate of ESRD in these patients with unknown proteinuria compared with macroproteinuric diabetic patients5 (0-4 vs 4-7% per year) could account for this observation.