Angiotensin inhibition in renovascular disease: A population-based cohort study
Received 28 January 2008; accepted 6 May 2008. published online 21 July 2008.
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.
aDivision of Clinical Pharmacology, University of Western Ontario, London, Ontario, Canada
bInstitute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
cDepartment of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
dDivision of Nephrology, University of Toronto, Toronto, Ontario, Canada
eDivision of Nephrology, University of Western Ontario, London, Ontario, Canada
Reprint requests: Daniel G. Hackam, Room 100K, Siebens Research Building 1400 Western Road, London, Ontario, Canada N6G 2V2.
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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