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Angiotensin-Converting Enzyme Inhibitors (ACEIs), Angiotensin II Receptor Antagonists (ARBs), or Direct Renin Inhibitors (DRI) for Adults With Hypertension

Slide: 14 of 16

Gaps in Knowledge

With the exception of rates of cough, the hypothesis that ACEIs, ARBs, and DRI have clinically meaningful differences in long-term outcomes in individuals with essential hypertension is not strongly supported by the available evidence. Given the importance of these issues, it is notable how few large, long-term, head-to-head studies have been published. Further comparative studies in this area should emphasize:

  • Long-term comparisons of the DRI with ACEIs and ARBs. Outcomes over several years will allow cardiovascular and cerebrovascular events to be compared between the three medication classes.
  • The impact of cough on quality of life, care patterns (e.g., use of therapeutic agents for cough symptoms or conditions associated with cough), and health outcomes, particularly for individuals who continue to use ACEIs.
  • Subgroups of special importance such as individuals with essential hypertension and diabetes mellitus, congestive heart failure, chronic kidney disease, and dyslipidemia.
  • Broader representation of groups such as the elderly and ethnic and racial minorities.
  • Clinical trials with long-term followup that report on the incidence of new cancer diagnoses and cancer deaths in patients on ACEIs, ARBs, or a DRI. Cancer-related outcomes are infrequently reported in the existing literature.
  • Evaluation of differential effects of specific ACEIs or ARBs that are not shared by other agents within their respective medication class.