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Published on: May 26, 2022
New Users of Angiotensin II Receptor Blocker-Versus Angiotensin-Converting Enzyme Inhibitor-Based Antihypertensive
Jordan B King1,2, Ransmond O Berchie1, Catherine G Derington1
1Intermountain Healthcare Department of Population Health Sciences University of Utah Spencer Fox Eccles School of Medicine UT Salt Lake City USA.
Insights
Angiotensin II receptor blockers (ARBs) and ACE inhibitors (ACEIs) showed similar cardiovascular event rates. However, ARBs were linked to lower overall death rates, with notable subgroup differences observed in this study.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) target distinct parts of the renin-angiotensin system.
- The comparative impact of ARBs versus ACEIs on cardiovascular disease (CVD) events requires further clarification.
Purpose of the Study:
- To compare the effects of ARB-based versus ACEI-based antihypertensive regimens on cardiovascular disease events and mortality.
- To analyze differential effects across various participant subgroups.
Main Methods:
- Emulation of target trials using data from the ACCORD-BP and SPRINT trials.
- Inverse probability of treatment weighting was used to compare new users of ARBs versus ACEIs.
- Analysis of cardiovascular disease events and death as primary and secondary outcomes, respectively.
Main Results:
- No significant difference in cardiovascular event rates between ARB and ACEI initiators (HR 0.81-0.91).
- ARBs were associated with a significantly lower death rate compared to ACEIs (HR 0.56).
- Significant subgroup differences observed, with ARBs showing benefits in males, non-Hispanic Black participants, and those on intensive blood pressure treatment.
Conclusions:
- ARB-based and ACEI-based antihypertensive regimens yield similar CVD event rates.
- ARBs demonstrate a potential survival benefit over ACEIs, with significant variations across demographic and treatment subgroups.
- Findings highlight the importance of individualized treatment selection in hypertension management.
Abstract:
BACKGROUND Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) block distinct components of the renin-angiotensin system. Whether this translates into differential effects on cardiovascular disease events remains unclear. METHODS AND RESULTS We used the ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure) trial and the SPRINT (Systolic Blood Pressure Intervention Trial) to emulate target trials of new users of ARBs versus ACEIs on cardiovascular disease events (primary outcome) and death (secondary outcome). We estimated marginal cause-specific hazard ratios (HRs) and treatment-specific cumulative incidence functions with inverse probability of treatment weights. We identified 3298 new users of ARBs or ACEIs (ACCORD-BP: 374 ARB versus 884 ACEI; SPRINT: 727 ARB versus 1313 ACEI). For participants initiating ARBs versus ACEIs, the inverse probability of treatment weight rate of the primary outcome was 3.2 versus 3.5 per 100 person-years in ACCORD-BP (HR, 0.91 [95% CI, 0.63-1.31]) and 1.8 versus 2.2 per 100 person-years in SPRINT (HR, 0.81 [95% CI, 0.56-1.18]). There were no appreciable differences in pooled analyses, except that ARBs versus ACEIs were associated with a lower death rate (HR, 0.56 [95% CI, 0.37-0.85]). ARBs were associated with a lower rate of the primary outcome among subgroups of male versus female participants, non-Hispanic Black versus non-Hispanic White participants, and those randomly assigned to standard versus intensive blood pressure (Pinteraction: <0.01, 0.05, and <0.01, respectively). CONCLUSIONS In this secondary analysis of ACCORD-BP and SPRINT, new users of ARB- versus ACEI-based antihypertensive medication regimens experienced similar cardiovascular disease events rates, with important subgroup differences and lower rates of death overall. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01206062, NCT00000620.
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