Efficacy of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in the Management of Left Ventricular Systolic Dysfunction According to Race, Gender and Diabetic Status

A Meta-Analysis of Major Clinical Trials

Published in: Journal of the American College of Cardiology, v. 41, no. 9, May 7, 2003, p. 1529-1538

Posted on RAND.org on January 01, 2003

by Paul G. Shekelle, Michael W. Rich, Sally C. Morton, Sidney W. Atkinson, Wenli Tu, Margaret Maglione, Shannon Rhodes, Michael Barrett, Gregg C. Fonarow, Barry Grennberg, Paul Heidenreich, Tom Knabel, Marvin A. Konstam, Anthony Steimle, Lynne Warner Stevenson

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This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes. Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established. The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups. Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality. Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.

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