Key result
In older patients, ARBs reduced stroke risk (RR 0.93; 95% CI 0.87-0.99) but had no benefit for all-cause mortality and increased the risk of acute kidney injury, hypotension, and hyperkalemia.
Why the study?
Do angiotensin receptor blockers improve clinical outcomes and what is their safety profile in patients aged 65 years or older?
Meta-Analysis (n=113,386)
Do angiotensin receptor blockers improve clinical outcomes and what is their safety profile in patients aged 65 years or older?
Relative Risk: 1.03 (95% CI 1–1.06)
p-value: p=0.05
In older patients (≥65 years), ARBs reduce the risk of stroke but are associated with significant increases in acute kidney injury, hypotension, and hyperkalemia, warranting cautious use.
Supports cautious ARB use in older adults for stroke prevention; reinforces risk-benefit trade-offs from prior trials.
BACKGROUND: The efficacy and safety of angiotensin receptor blockers (ARBs) in the older population is unclear. OBJECTIVES: To determine the efficacy and safety of ARBs in older patients. METHODS: Randomized trials that compared ARBs to control and reported clinical outcomes in patients with a mean age of 65 years or older were included. Random-effects summary risk ratios (RRs) were constructed. RESULTS: A total of 16 trials met our selection criteria, which yielded 113,386 patients. ARBs were associated with a marginal increased risk of all-cause mortality (RR: 1.03, 95% confidence interval (CI): 1.00-1.06, P = 0.05), a nonsignificant increased risk of myocardial infarction (RR: 1.04, 95% CI: 0.96-1.12, P = 0.36), a marginal reduction in heart failure hospitalization (RR: 0.86, 95% CI: 0.74-1.00, P = 0.06), and a significant reduction in the risk of stroke (RR: 0.93, 95% CI: 0.87-0.99, P = 0.03). ARBs were associated with an increased risk of acute kidney injury (RR: 1.48, 95% CI: 1.24-1.77, P < 0.001), hypotension (RR: 1.56, 95% CI: 1.24-1.97, P < 0.001), and hyperkalemia (RR: 1.57, 95% CI: 1.13-2.19, P = 0.008). On the sensitivity analysis including placebo-controlled trials, the risk of all-cause mortality was no longer significant (P = 0.2), while the remainder of the outcomes did not change. CONCLUSION: In older patients, the benefit of ARBs compared with control was strongest for stroke reduction, with no (or weak) associations for all-cause mortality, myocardial infarction, and heart failure hospitalization. Benefit was offset by an increased risk of acute kidney injury, hypotension, and hyperkalemia. Thus, ARBs should be used with caution in older patients when clinically indicated.
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Elgendy et al. (2014) reported a meta-analysis. Angiotensin receptor blockers (ARBs) vs. Control was evaluated on All-cause mortality (RR 1.03, 95% CI 1.00-1.06, p=0.05). In older patients, ARBs reduced stroke risk (RR 0.93; 95% CI 0.87-0.99) but had no benefit for all-cause mortality and increased the risk of acute kidney injury, hypotension, and hyperkalemia.
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