Home
Slides

Slide Tray

0 slides

View Empty Download

Return to Slide Library

Slides

Add Presentation to Slide Tray Presentation:

Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and/or Angiotensin II Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Slides: 1–12 of 29

This slide set is based on a comparative effectiveness review (CER) titled, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin II-Receptor Blockers (ARBs) Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease (IHD), that was developed by the University of Connecticut/Hartford Hospital Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) and is available online at effectivehealthcare.ahrq.gov (Contract No. 290-2007-10067-I). CERs represent comprehensive systematic reviews of the literature usually comparing two or more types of treatment, such as different drugs, for the same disease. Primary clinical trials were identified from searches of MEDLINE (1966 to February 2009), Embase (1974 to February 2009), and the Cochrane Central Register of Controlled Trials (1966 to February 2009). The methods used to develop this CER followed version 1.0 of the Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews published by AHRQ (draft available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf).

Add to tray Remove from tray

Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II-Receptor Blockers Added to Standard Medical Therapy for Treating Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: comparative effectiveness | effective health care | angiotensin-converting enzyme inhibitor | angiotensin II-receptor blocker | ischemic heart disease | left ventricular systolic function

Add to tray Remove from tray

Outline of Material

Keywords: effective health care | informed decisionmaking | key questions | comparative effectiveness

An estimated 80 million American adults (1 in 3) have one or more forms of cardiovascular disease. Among these adults, 38,100,000 are estimated to be age 60 or older, and about 16.8 million adults have ischemic heart disease, also known as coronary heart disease.

Add to tray Remove from tray

Health Impact of Cardiovascular Disease in the United States (1)

Keywords: cardiovascular disease | coronary heart disease | ischemic heart disease | health impact

Cardiovascular disease has been the leading cause of death in the United States in every year since 1900, except in 1918, accounting for more deaths than any other single cause or group of causes of death. Cardiovascular disease claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined. According to current data, nearly 2,400 Americans die of cardiovascular disease each day, an average of 1 death every 37 seconds.

Add to tray Remove from tray

Health Impact of Cardiovascular Disease in the United States (2)

Keywords: cardiovascular disease | ischemic heart disease | health impact

People with stable ischemic heart disease can have advanced atherosclerosis, which reduces the maximal ability of the coronary arteries to supply blood to the myocardium. Symptoms of stable ischemic heart disease range from asymptomatic ischemic episodes to severely debilitating symptoms and from large vessel disease to diffuse microvascular disease. People with stable ischemic heart disease may or may not have had an acute coronary syndrome in the past but are at increased risk of such an event in the future.

Add to tray Remove from tray

Characteristics of Stable Ischemic Heart Disease

Keywords: acute coronary syndrome | atherosclerosis | disease manifestation | stable ischemic heart disease | disease symptoms

In patients with stable ischemic heart disease, antiplatelet therapy with a single agent (aspirin or clopidogrel) and statin therapy (if the concentrations of low-density lipoprotein and non–high-density lipoprotein are above 100 mg/dL and 130 mg/dL, respectively) can reduce the risk of cardiovascular events. Other drugs — such as fast-acting nitrates (nitroglycerin tablets or spray), negative chronotropic agents (?-blockers; nondihydropyridine calcium channel blockers), and vasodilators (calcium channel blockers; long-acting nitrates) — can be used in patients with stable ischemic heart disease to relieve symptoms but do not impact the risk of cardiovascular events. For this reason, it is important to evaluate new therapeutic modalities that may impact cardiovascular events in patients with stable ischemic heart disease in addition to standard medical therapy.

Add to tray Remove from tray

Standard Therapy for Stable Ischemic Heart Disease

Keywords: cardiovascular events | standard therapy | stable ischemic heart disease

Despite standard medical therapy, patients with stable ischemic heart disease and preserved left ventricular systolic function continue to experience considerable morbidity and mortality. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II-receptor blockers (ARBs) have established benefit in patients with heart failure and left ventricular dysfunction. The available evidence for prophylactic use of ACEIs and ARBs in patients without heart failure and with preserved left ventricular systolic function is less clear.

Add to tray Remove from tray

Rationale for Additional Therapies for Patients With Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

Keywords: angiotensin II-receptor blocker | angiotensin-converting enzyme inhibitor | treatment rationale | stable ischemic heart disease

$A closer look at the current American College of Cardiology and American Heart Association guidelines reveals that angiotensin-converting enzyme inhibitors (ACEIs) are indicated for patients who have chronic heart failure or myocardial infarction and left ventricular dysfunction, which is defined as a left ventricular ejection fraction ?40%. Angiotensin II receptor blockers (ARBs) are reserved for patients who cannot tolerate ACEIs. In patients with heart failure, combining an ACEI with an ARB has been shown to provide additional benefits over an ACEI alone. However, it is unclear if ACEIs or ARBs impact the risk of future cardiovascular events in patients without left ventricular systolic dysfunction (LVSD).$

Add to tray Remove from tray

Guidelines for the Use of ACEIs, ARBs, or Both to Treat Patients With Cardiac Disease (1)

Keywords: American Heart Association | angiotensin II-receptor blocker | angiotensin-converting enzyme inhibitor | cardiac disease | guidelines | heart failure | American College of Cardiology

Clinical trials have been conducted to evaluate the use of ACEIs, ARBs, or both in patients with stable ischemic heart disease but without heart failure or left ventricular systolic dysfunction (patients with an LVEF >40%). Previous systematic reviews have not included recent ACEI trials conducted in this population. Additionally, no systematic review has evaluated ARB therapy or ACEI and ARB combination therapy in this population. From this body of evidence, the benefits and harms associated with the use of these therapies in this population of patients may be discerned.

Add to tray Remove from tray

Guidelines for the Use of ACEIs, ARBs, or Both to Treat Patients With Cardiac Disease (2)

Keywords: angiotensin II-receptor blocker | angiotensin-converting enzyme inhibitor | left ventricular systolic function | stable ischemic heart disease

Despite standard therapy, patients with stable ischemic heart disease and preserved left ventricular systolic function continue to be at risk for future cardiovascular events. The Renin-Angiotensin-Aldosterone System (RAAS) is critical for regulating blood pressure, electrolyte balance, and fluid volume homeostasis and plays a pivotal role in the pathogenesis of hypertension, congestive heart failure, and diabetic nephropathy. Pharmacological agonists of this system include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). These drugs block adverse effects of the RAAS by blocking the activity of angiotensin II. Through the stimulation of angiotensin II type-1 receptors, angiotensin II may have several potentially harmful activities including induction of aldosterone production, which can cause sodium retention and increased fluid retention that, in turn, leads to an increase in blood pressure, increased aldosterone production, which can possibly lead to promotion of pathogenic remodeling (i.e., atherosclerosis and fibrosis), constriction of blood vessels, which can lead to increased blood pressure, and potential reduction in the availability of nitric oxide through the production of free radicals and the induction of endothelial dysfunction that may impact endothelial wall integrity. ACEIs act on the RAAS by blocking the conversion of angiotensin I into angiotensin II and inhibiting the breakdown of bradykinin, which is a potent vasodilator. ARBs block the angiotensin II type-1 receptor and reduce the pharmacologic effects of angiotensin II, regardless of whether angiotensin II is created by the angiotensin-converting enzyme or by pathways that do not include this enzyme. ACEIs and ARBs may potentially provide several pharmacological effects over and above that of blood pressure reduction alone, which may impact cardiovascular events.

Add to tray Remove from tray

Pharmacologic Effects of Antagonists on the Renin-Angiotensin-Aldosterone System

Keywords: angiotensin II-receptor blocker | angiotensin-converting enzyme inhibitor | renin-angiotensin-aldosterone system | pharmacology

The comparative effectiveness review topic, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II-Receptor Blockers Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease, was nominated in a public process. Sufficient research into the current literature determined that there was a need for the available evidence on the addition of ACEIs and ARBs to standard medical therapy for patients with stable ischemic heart disease and preserved left ventricular systolic function (LVSF) and that there was an adequate number of clinical trials to be included in a comparative effectiveness review (CER). Based on this research, the Agency for Healthcare Research and Quality (AHRQ) commissioned the University of Connecticut/Hartford Hospital Evidence-Based Practice Center to prepare the CER with input from a Technical Expert Panel. This advisory panel was comprised of experts in different specialties, including cardiologists, a cardiovascular pharmacist/pharmacologist, and a health policy pharmacist. The panel identified important issues, reviewed proposed methods, defined parameters for the review of evidence, and helped to refine the key clinical questions that the research would subsequently address. Once formulated, the key clinical questions were published online and were made available for public commentary in order to refine the scope and focus of the research questions. A comprehensive systematic review of the literature was then conducted using several well-known databases, including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. All methods used in the review followed version 1.0 of AHRQ’s Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews (available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf) and the trial end points were determined a priori. Based on the findings of the review, a draft CER was prepared and published online for public comment, and the draft underwent rigorous peer review to improve the final product. After the CER was finalized, the complete report was published on the Internet (available at: http://effectivehealthcare.ahrq.gov/ehc/products/57/335/bodyfinal.pdf) and a condensed version was published in the Annals of Internal Medicine (available at: http://www.annals.org/content/early/2009/10/19/0003-4819-151-12-200912150-00162.full).

Add to tray Remove from tray

The CER Development Process

Keywords: effective health care | peer-review process | systematic review | comparative effectiveness

To determine the strength of the evidence resulting from the systematic review, researchers used the methodology of the University of Connecticut/Hartford Hospital Evidence-Based Practice Center for grading, which is based on the GRADE (Grading of Recommendations, Assessment, DEvelopment) system of the Cochrane Collaboration. This system uses four required domains — risk of bias, consistency, directness, and precision — for assessments. All assessments were made by two investigators who resolved disagreements through discussion. The strength of evidence pertaining to each key question was classified into three broad categories or grades:
1. High means that there are consistent results from good quality clinical trials. Further research is very unlikely to change the conclusions.
2. Moderate means that findings are supported, but further research could change the conclusions.
3. Low means that there are very few clinical trials, or existing trials are flawed.

Add to tray Remove from tray

Rating the Strength of Evidence From the CER: A Modification of the GRADE Methodology

Keywords: effective health care | GRADE | strength of evidence | comparative effectiveness

Pages: [1] 2 3 Next