Angiotensin-Converting Enzyme Inhibitors (ACEIs), Angiotensin II Receptor Antagonists (ARBs), or Direct Renin Inhibitors (DRI) for Adults With Hypertension
Evidence of Benefits: Clinical Outcomes
Few deaths or major cardiovascular events occurred in the identified studies comparing ACEIs, ARBs, and the DRI; this significantly limited any assessment of a differential effect of these drug classes on these events. In 21 studies that reported mortality, MI, or clinical stroke as outcomes among 38,589 subjects, 38 deaths and 13 strokes were reported. This may reflect low event rates among otherwise healthy patients and relatively few studies with extended followup. Only 3 of these 21 studies (including 1 death) evaluated the DRI versus ACEIs or ARBs, and therefore the evidence to discern any differential effects between these drug classes on mortality and major cardiovascular events was insufficient.
No significant difference was observed between ACEIs and ARBs in terms of their impact on quality of life. No evidence was available regarding the impact of the DRI on quality of life. There was no statistically evident difference in rate of treatment success based on use of a single antihypertensive medication for ARBs compared to ACEIs. No evidence regarding the effect of the DRI on this outcome was identified. Available evidence suggests that ACEIs and ARBs have a similar lack of effect on lipid levels for individuals with essential hypertension. No evidence regarding the effect of the DRI on these outcomes was available. Available evidence suggests that ACEI and ARBs are similar in their lack of effect on serum lipid levels, glucose levels, and HbA1c for individuals with essential hypertension. No evidence regarding the effect of the DRI on these outcomes was available. Evidence does not demonstrate a difference between ACEIs, ARBs, and the DRI with regard to their effect on left ventricular (LV) mass or function for individuals with essential hypertension. There are no consistently demonstrated differential effects related to renal function as measured by creatinine or glomerular filtration rate with use of ACEIs, ARBs, or the DRI. There appears to be a small difference in change in renal function favoring ACEIs over ARBs, but the clinical significance of these small effects is uncertain. There is a consistent finding of no differential effect related to reduction of urinary protein or albumin excretion among patients with essential hypertension with use of ACEIs, ARBs, or the DRI.
Keywords: clinical outcomes | ACEIs | ARBs | mortality | cardiovascular events | serum lipid levels | renal disease | quality of life
- Sanders GD, Coeytaux R, Dolor RJ, et al. Angiotensin-Converting Enzyme Inhibitors (ACEIs), Angiotensin II Receptor Antagonists (ARBs), and Direct Renin Inhibitors for Treating Essential Hypertension: An Update. Comparative Effectiveness Review No. 34. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 11-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2011. Available at: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=696.
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