NEW YORK (Reuters Health) -- Angiotensin receptor blockers (ARBs) are as safe and effective as angiotensin converting enzyme (ACE) inhibitors for treating hypertension in patients without heart failure, according to results of a new large meta-analysis.
"There has been debate for many years over the safety and efficacy of ACE inhibitors compared to ARBs, with many of them using an 'ACE inhibitor-first' approach, with ARBs regarded as less effective. We believe that our study ends the debate and gives physicians the option to prescribe either drug for their patients," lead author Sripal Bangalore, MD, of New York University said in a statement.
The reason why ACE inhibitors are thought to be more effective than ARBs for treating hypertension, Bangalore explains, stems from a "generation gap" in clinical trial data.
Trials of ACE inhibitors conducted from 1990 to 2000 showed a clear benefit (reduction in morbidity and mortality compared to placebo), but ARB trials done a decade later did not consistently show a mortality benefit over placebo.
Part of this may be explained by changes in the standard of care over the decade between the trials, with patients in the later ARB trials benefiting from more aggressive use of primary and secondary prevention strategies such as smoking cessation and statin use, making the impact of the ARB seem smaller compared to placebo.
To revisit the issue, the researchers did a meta-analysis of 106 relevant randomized trials that enrolled more than 254,000 patients.
Compared with placebo, ACE inhibitors but not ARBs reduced all-cause mortality, cardiovascular death, and myocardial infarction (MI), they report in the January issue of Mayo Clinic Proceedings.
For these outcomes, the meta-regression analysis revealed that the difference between ACE inhibitors and ARBs compared with placebo was due to a higher placebo event rate in the ACE inhibitor trials, most of which were conducted a decade earlier than the ARB trials.
Notably, say the researchers, sensitivity analyses restricted to trials published after 2000 revealed similar outcomes with ACE inhibitors versus placebo and ARBs versus placebo. Head-to-head comparison trials of ARBs versus ACE inhibitors showed no difference in outcomes except for a lower risk of drug withdrawal due to side effects with ARBs, they report.
"The take home message," Bangalore noted in email to Reuters Health, "is that in patients without heart failure the efficacy of ARBs is as good as that of ACEi with the added advantage of better tolerability. It is time to rethink the ACEi-first approach and consider both the medications equally."
"The data is robust enough to change clinical practice in the sense that both medications should be considered as reasonable choices. Tolerability should be a major factor to consider as well," Bangalore added.
"The results of our analysis are especially important for patients given that many ARBs are now also generic, which reduces their costs," Bangalore added in a statement.
Bangalore has received honorarium from Abbott, Boehringher Ingelheim, Daiichi Sankyo, Merck, Gilead, and Pfizer. The study had no commercial funding.
SOURCE:
Mayo Clin Proc 2016.