Elsevier

American Heart Journal

Volume 156, Issue 3, September 2008, Pages 549-555
American Heart Journal

Clinical Investigation
Coronary Artery Disease
Angiotensin inhibition in renovascular disease: A population-based cohort study

https://doi.org/10.1016/j.ahj.2008.05.013Get rights and content

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.

Section snippets

Setting

The sampling region for the study was the province of Ontario, Canada. Residents of Ontario who are 65 years or older have universal access to hospital care, physician services, and prescription drug coverage, with associated records entered into population-wide administrative databases. The study was approved by the Sunnybrook Health Sciences Ethics Board. The design and reporting of the protocol adhered to stringent observational research guidelines.15, 16

Data sources

We used 4 large administrative

Results

A total of 3,570 patients were enrolled in the study between 1994 and 2005; slightly more than half (n = 1,877, 53%) were treated with angiotensin inhibitors. The diagnosis of RVD was confirmed by duplex sonography in 52%, computerized tomographic angiography in 19%, renal angiography in 20%, and captopril renography in 18%; many patients had multiple imaging procedures. Cardiovascular risk factors and comorbidities were common with high rates of hypertension, chronic kidney disease, peripheral

Discussion

The presence of significant RVD has been viewed by many as a relative contraindication to the use of angiotensin inhibitors.38, 39, 40 Documented virtually since their introduction to market, cases of acute renal failure have been reported after initiation of angiotensin inhibitors in this setting.41, 42 Yet, several experts have called for broader use of angiotensin inhibitors in RVD and in the largest ongoing trial in this area, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions

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  • Cited by (0)

    The study was supported by an unrestricted research grant from the University of Western Ontario, London, Ontario, Canada. None of the funding sources participated in the design or conduct of the research; collection, management, analysis, or interpretation of the data; or the preparation, review, and approval of the manuscript.

    No conflicts of interest exist for D.G.H., M.L.D., M.M., P.L., or A.X.G. J.D.S. has consulted for Novartis and received lecture fees from Solvay. SWT has participated in research studies, advisory panels, and lectures with support from AstraZeneca, Abbott, Boehringer-Ingelheim, Bristol-Myers Squibb, Sanofi-Aventis, Merck, and Novartis.

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