Impact of Renin–Angiotensin–Aldosterone System Inhibitors on Liver‐Related Events and Mortality in Patients With Cirrhosis: A Meta‐Analysis of Real‐World Evidence

Background The therapeutic implications of renin–angiotensin–aldosterone system inhibitors (RAASi) in modulating liver‐related events (LREs) and mortality among patients with cirrhosis remain clinically uncertain. This meta‐analysis synthesizes real‐world evidence to clarify the association between RAASi use and clinical outcomes in this population. Methods We conducted a systematic literature search across PubMed, Embase, and Web of Science through December 25, 2024. Studies comparing LREs incidence or overall survival (OS) between patients with cirrhosis receiving RAASi versus non‐users were eligible. Pooled hazard ratios (HR) with 95% confidence intervals (CI) were calculated to obtain an overall estimate. Results Seven studies comprising nine cohorts ( N = 22 736) met inclusion criteria. RAASi use demonstrated a modest but significant reduction in LREs risk (HR, 0.81; 95% CI, 0.66–1.00; p = 0.0493) and significantly improved OS (HR, 0.73; 95% CI, 0.66–0.81; p < 0.0001). Subgroup analysis revealed particular benefit in hepatocellular carcinoma (HCC) prevention (HR, 0.88; 95% CI, 0.78–0.99; p = 0.0306). Conclusion This meta‐analysis suggests RAASi therapy may confer dual hepatoprotective and survival benefits in patients with cirrhosis, particularly regarding HCC prevention. While real‐world evidence indicates favorable risk reduction profiles, these findings warrant validation through prospective randomized trials to establish causality and optimize therapeutic protocols. Clinicians should consider individualized risk–benefit assessments when prescribing RAASi in this vulnerable population.