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Angiotensin receptor blockers and angiotensin-converting enzyme inhibitors: challenges in comparative effectiveness

S Setoguchi1, W H Shrank, J Liu

  • 1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. soko.setoguchi@duke.edu

Clinical Pharmacology and Therapeutics
|April 1, 2011
PubMed

Insights

Angiotensin receptor II blockers (ARBs) showed a reduced risk of sudden cardiac death (SCD) compared to angiotensin-converting enzyme inhibitors (ACEIs) in elderly patients. However, this benefit may be influenced by patient health-seeking behaviors and data limitations.

Area of Science:

  • Cardiology
  • Pharmacology
  • Geriatrics

Background:

  • An evidence gap exists regarding the comparative effectiveness of angiotensin receptor II blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) for hypertension.
  • ACEIs and ARBs are crucial in managing cardiovascular conditions like coronary artery disease (CAD), heart failure (HF), and stroke.

Purpose of the Study:

  • To compare the effectiveness of ARBs versus ACEIs in elderly hypertensive patients post-hospitalization for CAD, HF, or stroke.
  • To investigate the association between ACEI/ARB initiation and the risk of all-cause mortality and sudden cardiac death (SCD).

Main Methods:

  • Retrospective cohort study of elderly hypertensive patients eligible for Medicare and state pharmacy assistance programs.
  • Analysis included 18,801 ACEI initiators and 2,641 ARB initiators, with 2,535 deaths during follow-up.
  • Risk of SCD was compared between ARB and ACEI initiators, with subgroup analysis for patients with low ejection fraction (EF).

Main Results:

  • ARB initiators exhibited a lower incidence of death and SCD compared to ACEI initiators.
  • The relative risk for SCD was 0.69 (95% CI 0.50-0.96) for ARB versus ACEI initiators.
  • In patients with low ejection fraction, the relative risk for SCD was 1.1, suggesting potential confounding factors.

Conclusions:

  • While ARBs may offer a reduced risk of SCD compared to ACEIs in hypertensive patients, residual confounding due to unobserved health status is likely.
  • The findings highlight the need for further research, particularly with complete data on ejection fraction, to clarify the comparative effectiveness of these drug classes.

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