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ACE inhibitors and aortic rupture

2006; Elsevier BV; Volume: 368; Issue: 9547 Linguagem: Inglês

10.1016/s0140-6736(06)69655-4

1474-547X

Frank A. Lederle, Brent C Taylor,

Hemodynamic Monitoring and Therapy

Daniel Hackam and colleagues (Aug 19, p 659)1Hackam DG Thiruchelvam D Redelmeier DA Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study.Lancet. 2006; 368: 659-665Summary Full Text Full Text PDF PubMed Scopus (243) Google Scholar found that use of an angiotensin-converting-enzyme (ACE) inhibitor in the past year, including the past 3 months, was negatively associated with admission for ruptured abdominal aortic aneurysm (odds ratio 0·82, 95% CI 0·74–0·90). They also found that when the ACE inhibitor was discontinued (used in the past year but not in the past 3 months), patients were not protected from rupture. Hackam and colleagues regard this second finding as supporting their conclusion that ACE inhibitors are protective against rupture, an effect they attribute to inhibition of disease progression. What they do not emphasise in the paper is that, in the discontinued situation, the association was significant in the direction of ACE inhibitors being harmful (1·39, 1·09–1·77), and that the effect size was larger than the beneficial effect reported for current use. Hackam and colleagues need to explain how a drug could reduce disease progression if used in the past year, including the past 3 months, but worsen disease progression if used in the past year but not the past 3 months. Of note, their earlier paper,2Redelmeier D Scales D Kopp A Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study.BMJ. 2005; 331: 932Crossref PubMed Scopus (140) Google Scholar cited as the precedent for their definition of drug use, did not include the "3 months immediately before" proviso. It seems more appropriate to combine these two groups into "all patients who used ACE inhibitors in the past year", whereupon the opposite effects presumably cancel and the conclusion is no drug effect. We declare that we have no conflict of interest. ACE inhibitors and aortic rupture – Authors' replyFrank Lederle and Brent Taylor focus on our sensitivity analysis, which showed an increased risk of rupture in patients who discontinue angiotensin-converting-enzyme (ACE) inhibitors. One explanation might be confounding, which could occur if patients who are ill for other reasons become non-compliant or intolerant to ACE inhibitors (akin to the "healthy adherer" effect documented in previous research). This theory does not easily explain, however, why results with ACE inhibitors are not apparent with other drugs. Full-Text PDF