Fewer major CV events in patients on ARBs compared to ACEi in high-risk patients
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high vascular risk
Angiotensin receptor blockers (ARBs) and ACE inhibitors (ACEi) are widely used in patients with high cardiovascular (CV) risk. Although both drugs target the same mechanism, it is not clear whether they are similarly effective in prevention of CV events. Regarding this, data available from RCTs and meta-analyses reported conflicting results [1-4]. Both American and European guidelines for the management of patient with CV disease recommend ACEi as a first-choice therapy.
In this study, the effectiveness of ARBs and ACEi were compared using the observational cohort of the REACH registry, including 40 625 outpatients (age ≥45 yrs) with high CV risk and on ARBs (32.1%) or ACEi (67.9%). Primary outcome was the composite of CV mortality, non-fatal myocardial infarction (MI), non-fatal stroke or hospitalisation for CV disease at 4 years.
- Frequency of discontinuation study medication was similar in both groups.
- In the propensity score-adjusted cohort, rate of primary outcome was lower in ARB users than in ACEi users (HR 0.90, 95% CI 0.86-0.95, P<0.001).
- Also individual outcomes were lower in ARB users than in ACEi users: HR for CV mortality was 0.83 (95% CI 0.75-0.93, P=0.001), for CV hospitalisation 0.91 (95% CI 0.85-0.96, P<0.001) and for all-cause mortality 0.89 (95% CI 0.82-0.97, P=0.005). Number of non-fatal MIs and non-fatal stroke were not different between groups.
- Heart failure occurred equally in both groups (HR 0.96, 95% CI 0.88-1.06, P=0.418).
- Subgroup analysis showed similar results when accounting for history of diabetes or levels of eGFR.
- However, whereas there was no difference between ARB and ACEi for all outcomes for patients without atherosclerosis, there was in patients with established atherosclerosis, as ARB use was associated with a reduction of the primary outcome, CV mortality, hospitalisation for CV reasons or all-cause mortality, which interaction was only significant for CV mortality in both cohorts (P interaction = 0.03 in both cohorts).
- Also, ARB use was associated with a lower rate of non-fatal MI in patients with a history of heart failure, but not in patients without heart failure (P interaction 0.04 and 0.01 in propensity score-adjusted and matched cohort, respectively).
Compared to ACEi, ARB use was associated with a lower rate of major CV events in outpatients with high CV risk, which was consistent using two multiple adjustment methods. This difference between ARB and ACEi use was only significant in the subgroup of patients with established atherosclerosis. These results suggest that ARBs should be preferred over ACEIs in patients with a previous history of CV diseases.