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

Slide: 6 of 16

Rationale for Update

In 2007, the Agency for Healthcare Research and Quality (AHRQ) published its first systematic review on the comparative effectiveness of ACEIs, ARBs, and the DRI aliskiren for adults with hypertension. It is an update of a 2007 report that evaluated the scientific literature on ACEIs and ARBs for adults with essential hypertension and adds an evaluation of the DRI aliskiren, which was not covered in the original report. The need for this updated report was determined by an analysis conducted by the Southern California Evidence-based Practice Center. In that analysis, investigators assessed the conclusions from the original comparative effectiveness review, performed a limited literature search of potentially new evidence, and solicited expert opinions concerning the state of the evidence and validity of the original report. The outcomes analyzed in this comparison are the relative benefits (i.e., blood pressure control, cardiovascular risk reduction, cardiovascular events, quality of life, and other outcomes), as well as safety (i.e., adverse events, tolerability, persistence with drug therapy, and treatment adherence). The clinical determinants of these outcomes were also examined, such as age, race, ethnicity, sex, comorbidities, and concurrent use of other medications. The focus is on long-term outcomes and impact. Although ACEIs, ARBs and the DRI are highly effective in lowering blood pressure among patients with essential hypertension, the comparative effectiveness of these medication classes is not known. ACEIs and ARBs are the second and fifth most commonly prescribed medications for hypertension, respectively, and the use of DRIs has been rising since their introduction. Although ACEIs and ARBs are occasionally used in combination, such combinations provide little blood pressure lowering over each agent used alone, and are associated with increased adverse events. As a result, most providers choose to use either an ACEI or an ARB for hypertension. It is therefore important to understand the comparative effectiveness of these agents for providers making this choice.