Article

Secondary prevention of coronary artery disease and the choice of the ACE inhibitor why EUROPA and not PEACE.

Cardiovascular Drugs and Therapy (Impact Factor: 2.95). 01/2008; 21(6):405-7. DOI: 10.1007/s10557-007-6071-x
Source: PubMed
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    ABSTRACT: Objective The aim of the study is to determine the extent of lost therapeutic benefit (LTB) in the hypertensive patients, and to determine the relationship between the presence of LTB and clinical outcomes. Methods Prospective-cohort study of n = 2856 patients with or at high risk of atherothrombosis. LTB was calculated as the proportion of patients receiving blood pressure medication who were not attaining guideline blood pressure (BP) control targets (<140/90 mmHg). Logistic regression analysis was performed to identify predictors of LTB at baseline, and propensity score matching (PSM) was undertaken to estimate the treatment effects by matching case LTB and control non-LTB cohorts based on the nearest neighbor matching. ResultsOf the total sample of 2856, 45.6% had uncontrolled BP, and LTB was present in 46.7% patients. The likelihood of LTB was less in males (OR = 0.78 [95% CI; 0.64–0.97]), and those with a previous myocardial infarction (OR = 0.66 [0.53–0.81]) or heart failure (OR = 0.58 [0.42–0.82]). LTB was more common in those with diabetes (OR = 1.44 [1.16–1.79]), aged >65 years (OR = 1.36 [1.06–1.75]) and having an ABI < 0.09 in either leg at rest (OR = 1.30 [1.02–1.75]). Following PSM, the combination of ischemic events (55–64 age category) was more likely to occur in the LTB compared with non-LTB group (4.38% and 0.68%, respectively [P = 0.046]). Conclusion Presence of HF, previous MI and being male decreased the likelihood of LTB, while presence of diabetes, age > 65 and ABI < 0.09 increased the risk of LTB. Patients with LTB in age category 55–64 had higher incidence of vascular events compared with those with non-LTB.
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    ABSTRACT: AimsWe determined whether blood pressure (BP) lowering by perindopril was related to its benefit in the EUROPA study. Methods and resultsTwelve thousand two hundred eighteen patients with documented coronary artery disease received perindopril 8mg once daily or matching placebo after a 4-week run-in period in which all patients received perindopril. Patients were excluded if systolic (S) BP was >180 or <100mmHg. Mean age was 60years (range 26–89). 27% had a history of hypertension. After 4.2years of follow-up, the primary endpoint (cardiovascular death, nonfatal myocardial infarction, or resuscitated cardiac arrest) was observed in 603 (9.9%) placebo versus 488 (8.0%) perindopril patients [20% relative risk reduction (RRR), CI 9–29%, P = 0.003]. There was no interaction between baseline SBP levels (using JNC-7 cutoff values) and treatment effect. If anything, the greatest RRR of the primary endpoint (32%) occurred in patients with the lowest SBP (<120mmHg) in whom perindopril did not reduce SBP. Also, RRR during blinded treatment was comparable, irrespective of whether BP decreased or not or of the extent of BP reduction during perindopril treatment. ConclusionThe treatment benefit in EUROPA cannot be fully explained by baseline BP or BP reduction with perindopril. Other mechanisms including direct anti-atherosclerotic effects of ACE inhibition may play a role.
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