Evidence map›Paper›PMID 23358488›Full record

SynthesisBMJ (Clinical research ed.)2013

Efficacy and safety of dual blockade of the renin-angiotensin system: meta-analysis of randomised trials.

Harikrishna Makani, Sripal Bangalore, Kavit A Desouza, Arpit Shah, Franz H Messerli

Open access · hybridAbstract readMeta-AnalysisSystematic Review
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in BMJ (Clinical research ed.), 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 88 papers, 13 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
88citing papers in PubMed, 13 pooled it
22.2field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

88 citing papers in PubMed, 13 syntheses or guidelines pooled it, 243 citations in OpenAlex.

  1. Guideline
  2. Guideline
  3. Pooled it
  4. Guideline
  5. Pooled it
  6. Pooled it
  7. Pooled it
  8. Pooled it
  9. Pooled it
  10. Pooled it
  11. Pooled it
  12. Active vitamin D treatment for reduction of residual proteinuria: a systematic review.Journal of the American Society of Nephrology : JASN · 2013
    Pooled it
  13. Pooled it
  14. Trial
  15. Trial
  16. Trial
  17. Review
  18. Observational
  19. Review
  20. Article

28 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

5 authors at 3 institutions in 1 country.

Harikrishna MakaniDivision of Cardiology, St Luke's Roosevelt Hospital, Columbia University College of Physicians and Surgeons, 1000 10th Avenue, New York, NY 10019, USA.
Sripal Bangalore
Kavit A Desouza
Arpit Shah
Franz H Messerli
St. Luke's-Roosevelt Hospital Center · USColumbia University · USNew York University · US

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectiveTo compare the long term efficacy and adverse events of dual blockade of the renin-angiotensin system with monotherapy.

designSystematic review and meta-analysis. DATA SOURCES: PubMed, Embase, and the Cochrane central register of controlled trials, January 1990 to August 2012. STUDY SELECTION: Randomised controlled trials comparing dual blockers of the renin-angiotensin system with monotherapy, reporting data on either long term efficacy (≥ 1 year) or safety events (≥ 4 weeks), and with a sample size of at least 50. Analysis was stratified by trials with patients with heart failure versus patients without heart failure.

results33 randomised controlled trials with 68,405 patients (mean age 61 years, 71% men) and mean duration of 52 weeks were included. Dual blockade of the renin-angiotensin system was not associated with any significant benefit for all cause mortality (relative risk 0.97, 95% confidence interval 0.89 to 1.06) and cardiovascular mortality (0.96, 0.88 to 1.05) compared with monotherapy. Compared with monotherapy, dual therapy was associated with an 18% reduction in admissions to hospital for heart failure (0.82, 0.74 to 0.92). However, compared with monotherapy, dual therapy was associated with a 55% increase in the risk of hyperkalaemia (P<0.001), a 66% increase in the risk of hypotension (P<0.001), a 41% increase in the risk of renal failure (P=0.01), and a 27% increase in the risk of withdrawal owing to adverse events (P<0.001). Efficacy and safety results were consistent in cohorts with and without heart failure when dual therapy was compared with monotherapy except for all cause mortality, which was higher in the cohort without heart failure (P=0.04 v P=0.15), and renal failure was significantly higher in the cohort with heart failure (P<0.001 v P=0.79).

conclusionAlthough dual blockade of the renin-angiotensin system may have seemingly beneficial effects on certain surrogate endpoints, it failed to reduce mortality and was associated with an excessive risk of adverse events such as hyperkalaemia, hypotension, and renal failure compared with monotherapy. The risk to benefit ratio argues against the use of dual therapy.

Indexed as

Angiotensin-Converting Enzyme InhibitorsAngiotensin Receptor AntagonistsDrug Therapy, CombinationFemaleHeart FailureHospitalizationHumansHyperkalemiaHypotensionMaleMiddle AgedRandomized Controlled Trials as TopicRenal InsufficiencyRenin-Angiotensin SystemTreatment OutcomeAngiotensin-Converting Enzyme InhibitorsAngiotensin Receptor Antagonists

Identifiers

PMID23358488
PMCPMC3556933
OpenAlexW2092057051

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.