RecommendationConsider angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line with relevant NICE guidance.
Relative values of different outcomesThe GDG were interested in intermediate and longterm morbidity and mortality outcomes when evaluating the value of ACE inhibitors for people with stable angina.
Trade off between clinical benefits and harmsEvidence from one large trial (HOPE) suggests that ACE inhibitors reduce the combined end point of MI, stroke or death from cardiovascular causes, and the rates of stroke and revascularisation. Two RCTs (HOPE, QUIET) showed lower all cause death with ACE inhibitors. Two large trials (HOPE, PEACE) showed significantly lower rates of hospitalisation due to heart failure with ACE inhibitors. Combined evidence from three randomised trials (HOPE, QUIET, PEACE) showed death from cardiovascular causes, non fatal MI, and revascularisation to be significantly lower with use of ACE inhibitors.

There was no evidence available for ARB’s in the management of stable angina.
Economic considerationsThere is a low additional cost of adding ACE-inhibitors to standard treatment while the clinical evidence showed significant improvements in health outcomes for some patients. Therefore ACE-inhibitors are likely to be cost-effective.
Quality of evidenceModerate and high quality evidence for outcomes was available.

No economic evidence was available on this question.
Other considerationsThe GDG noted that use of other medications and some population characteristics differed in the studies available for this review. In the PEACE trial 90% of patients were taking aspirin and 70% were taking lipid lowering drugs. 18% of the population was diabetic. In this trial there was no significant effect from ACE inhibitors on major end points. In the HOPE trial 38% of the population was diabetic and 75% were taking aspirin and 28% lipid lowering drugs. This trial showed reduced combined cardiac events. The GDG considered that the evidence did not indicate that all people with angina should be offered an ACE inhibitor. The GDG considered that patients who have had a myocardial infarction will already be on an ACE inhibitor as will many patients for hypertension, heart failure or kidney disease. The GDG considered that the evidence suggested potential benefit for diabetic patients and if diabetic patients are not already taking ACE inhibitor health care professionals should consider offering ACE inhibitors.

From: 13, Secondary prevention

Cover of Stable Angina
Stable Angina: Methods, Evidence & Guidance [Internet].
NICE Clinical Guidelines, No. 126.
National Clinical Guidelines Centre (UK).
Copyright © 2011, National Clinical Guidelines Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of the National Clinical Guidelines Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.