Angiotensin Inhibition in Renovascular Disease
Background: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers effectively reduce blood pressure in patients with renovascular disease (RVD); yet, randomized cardiovascular prevention trials of these drugs typically exclude individuals with this condition.
Patients and Methods: We studied the association of renin-angiotensin system inhibition with prognosis in a population-based cohort comprising 3,570 patients with RVD in Ontario, Canada; slightly more than half (n = 1,857, 53%) were prescribed angiotensin inhibitors. The primary outcome was the composite of death, myocardial infarction, or stroke. Secondary outcomes included individual cardiovascular and renal events.
Results: Patients receiving angiotensin inhibitors had a significantly lower risk for the primary outcome during follow-up (10.0 vs 13.0 events per 100 patient-years at risk, multivariable adjusted hazard ratio [HR] 0.70, 95% CI 0.59-0.82). In addition, hospitalization for congestive heart failure (HR 0.69, 95% CI 0.53-0.90), chronic dialysis initiation (HR 0.62, 95% CI 0.42-0.92), and mortality (HR 0.56, 95% CI 0.47-0.68) was lower in treated patients. Conversely, patients receiving angiotensin inhibitors were significantly more likely to be hospitalized for acute renal failure during follow-up (HR 1.87, 95% CI 1.05-3.33; 1.2 vs 0.6 events per 100 patient-years at risk).
Conclusions: These data emphasize the high vascular risk of RVD and suggest that angiotensin inhibitors may improve prognosis in this setting at the expense of acute renal toxicity. If the latter are selected in the management of RVD, renal function parameters should be assiduously followed.
Atherosclerotic renovascular disease (RVD) is a prevalent clinical entity with complex treatment implications. In relatively healthy community-dwelling individuals older than 65 years, the prevalence of RVD approaches 7%. Some evidence suggests that the frequency of RVD has increased in recent years, possibly driven by an ageing population and reduced mortality for other major causes of death. Yet, the most important implication of RVD is the high risk of cardiovascular events associated with this condition. In a follow-up study of elderly individuals with newly diagnosed RVD, the annual incidence of coronary events, stroke, heart failure, and death was 30%, 18%, 19%, and 17%, respectively.
These considerations suggest that the management of RVD should include intensive medical therapy. Because renin-angiotensin system activation is present in many patients with RVD, some experts have called for wider use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in this setting (hereafter termed angiotensin inhibitors). In a recent series of 146 consecutive patients with documented RVD, nearly three quarters were taking ACE inhibitors. Preclinical evidence suggests this approach may have merit: a meta-analysis of 15 animal studies found that angiotensin inhibitors reduced mortality in RVD by 85% (summary odds ratio 0.15, 95% CI 0.09-0.25).
On the other hand, many clinicians are reluctant to use angiotensin inhibitors in this setting out of fear of precipitating acute renal failure and hyperkalemia. Unfortunately, large randomized trials of angiotensin inhibitors for secondary prevention typically exclude patients with known history of RVD. In addition, a recent search of trial registration databases found no study of angiotensin inhibition in RVD to be underway. In light of these limitations, we performed a longitudinal population-based cohort study to evaluate the impact of angiotensin inhibition on cardiovascular and renal events in patients with RVD.
Abstract and Background
Abstract
Background: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers effectively reduce blood pressure in patients with renovascular disease (RVD); yet, randomized cardiovascular prevention trials of these drugs typically exclude individuals with this condition.
Patients and Methods: We studied the association of renin-angiotensin system inhibition with prognosis in a population-based cohort comprising 3,570 patients with RVD in Ontario, Canada; slightly more than half (n = 1,857, 53%) were prescribed angiotensin inhibitors. The primary outcome was the composite of death, myocardial infarction, or stroke. Secondary outcomes included individual cardiovascular and renal events.
Results: Patients receiving angiotensin inhibitors had a significantly lower risk for the primary outcome during follow-up (10.0 vs 13.0 events per 100 patient-years at risk, multivariable adjusted hazard ratio [HR] 0.70, 95% CI 0.59-0.82). In addition, hospitalization for congestive heart failure (HR 0.69, 95% CI 0.53-0.90), chronic dialysis initiation (HR 0.62, 95% CI 0.42-0.92), and mortality (HR 0.56, 95% CI 0.47-0.68) was lower in treated patients. Conversely, patients receiving angiotensin inhibitors were significantly more likely to be hospitalized for acute renal failure during follow-up (HR 1.87, 95% CI 1.05-3.33; 1.2 vs 0.6 events per 100 patient-years at risk).
Conclusions: These data emphasize the high vascular risk of RVD and suggest that angiotensin inhibitors may improve prognosis in this setting at the expense of acute renal toxicity. If the latter are selected in the management of RVD, renal function parameters should be assiduously followed.
Background
Atherosclerotic renovascular disease (RVD) is a prevalent clinical entity with complex treatment implications. In relatively healthy community-dwelling individuals older than 65 years, the prevalence of RVD approaches 7%. Some evidence suggests that the frequency of RVD has increased in recent years, possibly driven by an ageing population and reduced mortality for other major causes of death. Yet, the most important implication of RVD is the high risk of cardiovascular events associated with this condition. In a follow-up study of elderly individuals with newly diagnosed RVD, the annual incidence of coronary events, stroke, heart failure, and death was 30%, 18%, 19%, and 17%, respectively.
These considerations suggest that the management of RVD should include intensive medical therapy. Because renin-angiotensin system activation is present in many patients with RVD, some experts have called for wider use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in this setting (hereafter termed angiotensin inhibitors). In a recent series of 146 consecutive patients with documented RVD, nearly three quarters were taking ACE inhibitors. Preclinical evidence suggests this approach may have merit: a meta-analysis of 15 animal studies found that angiotensin inhibitors reduced mortality in RVD by 85% (summary odds ratio 0.15, 95% CI 0.09-0.25).
On the other hand, many clinicians are reluctant to use angiotensin inhibitors in this setting out of fear of precipitating acute renal failure and hyperkalemia. Unfortunately, large randomized trials of angiotensin inhibitors for secondary prevention typically exclude patients with known history of RVD. In addition, a recent search of trial registration databases found no study of angiotensin inhibition in RVD to be underway. In light of these limitations, we performed a longitudinal population-based cohort study to evaluate the impact of angiotensin inhibition on cardiovascular and renal events in patients with RVD.
Source...