Chronic Stable Angina: Angiotensin-Converting Enzyme Inhibitor Therapy and/or Calcium-Channel Blocker Therapy—When is it Indicated?

Abstract

Objective:

To discuss outcomes data assessing the use of angiotensin-converting enzyme (ACE) inhibitors and calcium-channel blockers (CCBs) in the prevention of cardiovascular events in patients with chronic stable angina that have been published since the 2002 American College of Cardiology/American Heart Association (ACC/AHA) updated guidelines for the treatment of chronic stable angina.

Data Sources:

A MEDLINE search (2002–April 2006) identified 60 primary, review, and meta-analysis articles. The inclusion criteria were: patients with stable coronary artery disease, chronic stable angina, or coronary heart disease; evaluation of long-term therapy with either ACE inhibitor or CCB therapy; prospective, randomized, controlled clinical trials; cardiovascular events as the primary endpoint of the study; and date of publication after the 2002 ACC/AHA guidelines.

Study Selection and Data Extraction:

All articles identified from the literature search were evaluated, and all clinical trials deemed relevant were included in this review. Six randomized trials met inclusion criteria and evaluated the utility of ACE inhibitor and CCB therapy in reducing cardiovascular events in patients with coronary artery disease and/or chronic stable angina.

Data Synthesis:

Patient populations, background therapy, and the study endpoints of all 6 trials varied. However, all primary endpoints assessed cardiovascular events. Two of the 3 ACE inhibitor trials demonstrated a significant reduction in the primary endpoint and 1 of the 3 CCB trials demonstrated a significant reduction in the primary endpoint.

Conclusions:

Newer evidence cumulatively supports the addition of an ACE inhibitor to standard antianginal pharmacotherapy to reduce the risk of cardiovascular events. However, benefit is influenced by severity of illness and use of additional cardiovascular risk reduction pharmacotherapy. The level of supporting evidence for ACE inhibitor therapy in chronic stable angina is higher than that cited in the 2002 ACC/AHA guidelines. Newer evidence evaluating the use of CCBs to prevent cardiovascular events in patients with stable coronary artery disease is controversial and remains consistent with the 2002 guidelines.