ACE inhibitors perform better than ARBs, new study shows

ANGIOTENSIN-converting enzyme (ACE) inhibitors show a clear clinical advantage over angiotensin receptor blockers (ARBs), a meta-analysis shows.

Investigators who set out to study the impact of renin-angiotensin-aldosterone system (RAAS) inhibitors as a whole were surprised when their stratified analysis showed stark differences between the two different types.

ACE inhibitors were associated with a 10% drop in all-cause mortality, whereas no mortality reduction was shown with ARBs.

The analysis of 20 trials with almost 160,000 patients showed that overall, RAAS inhibitors led to a 5% reduction in all-cause mortality in the four-year follow-up.

But noting that ACE inhibitors and ARBs had different mechanisms, the researchers decided to break down the results further, finding that the overall reduction “was almost completely the result of the beneficial effect of the class of ACE inhibitors… whereas the ARBs showed a neutral treatment effect”.

The authors said the findings should be treated with caution until further research is done.

“At present, the results of this analysis do not warrant changing clinical practice treatment guidelines,” they wrote.
Dr Rob Grenfell, national director of clinical issues for the Heart Foundation, agreed with those conclusions.

“Our recommendations still say that an ACE inhibitor is first-line medication, and that an ARB is the second-line treatment if the patient is intolerant to an ACE inhibitor,” he said.

Limitations of the study included that the meta-analysis involved mainly controlled populations that might not reflect real world patients, he said.

The study highlighted the importance of reaching treatment targets but patient adherence to medication remained a challenge.

“Recent polling done by the Heart Foundation found that 40% of the people being treated for hypertension don’t know what hypertension does,” he said. “They don’t know why their blood pressure is being treated.”

Eur Heart J 2012, online 17 April