Objective ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely prescribed in patients with high cardiovascular (CV) risk. However, whether both classes have equivalent effectiveness to prevent CV events remains unclear. The aim of this study was to compare the incidence of major CV events between ACEI and ARB users.
Methods The Reduction of Atherothrombosis for Continued Health registry is an observational study who enrolled 69 055 individuals with high CV risk. Among them, 40 625 patients (ACEIs 67.9% and ARBs 32.1%) were included. Main outcome was rates of CV mortality, non-fatal myocardial infarction, non-fatal stroke or hospitalisation for CV disease at 4 years.
Results In a propensity score-adjusted cohort, the incidence of the primary outcome was lower in patients on ARBs compared with ACEIs (29.2% vs 33.4%; adjusted HR 0.90; 95% CI 0.86 to 0.95; p<0.001). Similar results were observed for CV (6.9% vs 8.2%; HR 0.83; 95% CI 0.75 to 0.93; p=0.001) and all-cause mortality (11.6% vs 12.6%; HR 0.89; 95% CI 0.82 to 0.97; p=0.005). Analyses using propensity score matching yielded similar results. History of diabetes or estimated glomerular filtration rate did not affect the results. ARB use was associated with lower rates of all-cause mortality in secondary prevention but not in primary prevention patients (p-value for interaction=0.03).
Conclusion ARB use appears to be associated with 10% lower rates of CV events compared with ACEIs, especially in patients with established CV disease. Our results suggest that ARBs may provide superior protection against CV events than ACEIs in high-risk patients in real-world practice.
- Cardiac risk factors and prevention
- Coronary artery disease
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Contributors Drafting the work: LP, RR, YE; Revising the work critically for important intellectual content: YE, MM, UZ, CMR, EMO, KAE, DLB, PGS; Substantial contributions to the conception or design of the work, and the acquisition of data: UZ, CMR, EMO, KAE, DLB and PGS; Substantial contributions to analysis or interpretation of data: LP, RR, YE, MM, PGS; Final approval of the version published: LP, RR, YE, MM, UZ, CMR, EMO, KAE, DLB, PGS.
Funding The REACH Registry is endorsed by the World Heart Federation. The REACH Registry was supported by Sanofi-Aventis, Bristol-Myers Squibb, and the Waksman Foundation (Tokyo, Japan).
Competing interests Dr LP reports grants and personal fees from Sanofi, personal fees from Servier, outside the
submitted work; Dr RR reports grants and personal fees from Sanofi, personal fees from
AstraZeneca, personal fees and non-financial support from Novartis, personal fees from
MSD, outside the submitted work; M. YE has nothing to disclose; Dr MM reports grants
and personal fees from MSD, Novartis, Novo Nordisk, Sanofi and Servier, personal fees and
non-financial support from Abbott, Intarcia, and Eli Lilly, outside the submitted work; Dr
UZ reports personal fees from Astra Zeneca, personal fees from Boehringer Ingelheim,
personal fees from Novartis, personal fees from BMS, personal fees from Sanofi, personal
fees from MSD, personal fees from Pfizer, outside the submitted work; Dr. Reid reports
grants from Sanofi Aventis, during the conduct of the study; Dr MO reports personal fees
from Abbott Vascular, personal fees from Abiomed, personal fees from Astra Zeneca, personal fees from Biotie, personal fees from Boehringer Inelheim, personal fees from Bristol Myers Squibb, grants and personal fees from Daiichi Sankyo, personal fees from Faculty
Connection, grants from Gilead Sciences, grants and personal fees from Janssen Parmaceuticals, personal fees from Merck, personal fees from Sanofi Aventis, personal fees
from St. Jude Medical, personal fees from Stealth eptides, personal fees from The Medicines
Company, personal fees from Medscape, outside the submitted work; Dr KAE has nothing
to disclose; D.L.B. reports grants from Bristol Myers Squibb, grants from Sanofi Aventis,
during the conduct of the study; grants from Amarin, grants from AstraZeneca, grants from
Bristol-Myers Squibb, grants from Eisai, grants from Ethicon, grants from Medtronic, grants
from sanofi aventis, grants from The Medicines Company, other from FlowCo, other from
PLx Pharma, other from Takeda, personal fees from Duke Clinical Research Institute,
Personal fees from Mayo Clinic, personal fees from Population Health Research Institute,
personal fees and non-financial support from American College of Cardiology, personal fees from Belvoir Publications, personal fees from Slack Publications, personal fees from
WebMD, personal fees from Elsevier, other from Medscape Cardiology, other from Regado
Biosciences, other from Boston VA Research Institute, personal fees and non-financial
support from Society of Cardiovascular Patient Care, non-financial support from American Heart Association, personal fees from HMP Communications, grants from Roche, personal fees from Harvard Clinical Research Institute, other from Clinical Cardiology, personal fees from Journal of the American College of Cardiology,
other from VA, grants from Pfizer, grants from Forest Laboratories, grants from Ischemix,
other from St. Jude Medical, other from Biotronik, other from Cardax, other from Ameri
can College of Cardiology, other from Boston Scientific, grants from Amgen, outside the
submitted work; Dr PG reports personal fees from BMS and Sanofi, during the conduct of the
study; grants from Merck, Sanofi, and Servier, personal fees from Amarin, AstraZeneca, Ba
yer, Boehringer-Ingelheim, Bristol-Myers-Squibb, CSL-Behring, Daiichi-Sankyo, GlaxoSmithKline, Janssen, Lilly, Merck Novartis, Pfizer, Regeneron, Sanofi, Servier, The M
edicines Company, outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.
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