Key result
ARBs match ACE inhibitors for cardiovascular outcomes while causing fewer adverse events and withdrawals.
Why the study?
Most guidelines recommend ACE inhibitors as first-choice therapy and ARBs only as an alternative, prompting a direct comparison of outcomes and adverse events between the two classes.
Do angiotensin receptor blockers (ARBs) improve outcomes or reduce adverse events compared to angiotensin-converting enzyme (ACE) inhibitors in patients with hypertension?
Do angiotensin receptor blockers (ARBs) improve outcomes or reduce adverse events compared to angiotensin-converting enzyme (ACE) inhibitors in patients with hypertension?
Given equal efficacy and fewer adverse events, ARBs should be considered over ACE inhibitors for hypertension, challenging current guideline recommendations.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Ever since the HOPE study, published in 2000, ACE inhibitors have become a sacred cow and nobody dared to say anything against them.”
“However, because neither of these ARB trials gave as clear a demonstration of benefit as the prior ACE-inhibitor trials in heart failure, ACE inhibitors remain preferred over ARBs.”
May favor ARBs for tolerability in hypertension; leaves open effects on adherence and outcomes.
Most guidelines for the management of patients with cardiovascular disease recommend angiotensin-converting enzyme (ACE) inhibitors as first-choice therapy, whereas angiotensin receptor blockers (ARBs) are merely considered an alternative for ACE inhibitor-intolerant patients. The aim of this review was to compare outcomes and adverse events between ACE inhibitors and ARBs in patients. In patients with hypertension and hypertension with compelling indications, we found no difference in efficacy between ARBs and ACE inhibitors with regard to the surrogate endpoint of blood pressure and outcomes of all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease. However, ACE inhibitors remain associated with cough and a very low risk of angioedema and fatalities. Overall withdrawal rates because of adverse events are lower with ARBs than with ACE inhibitors. Given the equal outcome efficacy but fewer adverse events with ARBs, risk-to-benefit analysis in aggregate indicates that at present there is little, if any, reason to use ACE inhibitors for the treatment of hypertension or its compelling indications.
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Messerli et al. (2018) conducted a review in Hypertension. Angiotensin receptor blockers (ARBs) vs. Angiotensin-converting enzyme (ACE) inhibitors was evaluated on Blood pressure, all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease. Angiotensin receptor blockers (ARBs) demonstrated equal efficacy to ACE inhibitors for cardiovascular outcomes in hypertension, but with fewer adverse events and lower withdrawal rates.
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