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Comparative Effectiveness of ACE Inhibitors and Angiotensin Receptor Blockers for Cardiovascular Disease Prevention
Tom Forzy1, Henock G Yebyo1, Gregory M Lucas2
1Epidemiology, Biostatistics and Prevention Institute, Department of Epidemiology, University of Zurich, Zurich, Switzerland.
Insights
Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) effectively reduce cardiovascular disease (CVD) risk in people with HIV (PWH). These antihypertensive medications demonstrated similar effectiveness in preventing primary CVD events.
Area of Science:
- Cardiology
- Infectious Diseases
- Pharmacology
Background:
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are established treatments for hypertension and cardiovascular disease (CVD) risk reduction.
- The comparative effectiveness of ACEIs and ARBs in people with HIV (PWH) remains under-examined.
- This study addresses the need to evaluate these antihypertensive drug classes in the PWH population.
Purpose of the Study:
- To compare the effectiveness of ACEIs and ARBs against each other and against no antihypertensive treatment.
- To assess the primary outcome of preventing incident cardiovascular disease (CVD) in hypertensive PWH.
- To conduct subgroup analyses based on race.
Main Methods:
- Utilized a target trial emulation framework with data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).
- Estimated intention-to-treat (ITT) and per-protocol (PP) effects of ACEIs and ARBs.
- Defined primary CVD events including myocardial infarction, non-MI coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease, and cardiovascular death.
Main Results:
- Both ACEIs and ARBs significantly reduced CVD risk in PWH compared to no antihypertensive treatment, with comparable effect sizes in ITT and PP analyses.
- Head-to-head comparisons showed similar effectiveness between ACEIs and ARBs overall and within racial subgroups.
- Race-stratified analyses indicated potentially greater risk reductions in White PWH than Black PWH, but these differences were not statistically significant.
Conclusions:
- ACEIs and ARBs are both effective in reducing CVD risk among PWH.
- No statistically significant differences in effectiveness were found between ACEIs and ARBs in this population.
- The study did not find significant differences in medication effectiveness between Black and White PWH.
Background:
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are established antihypertensive treatments that reduce cardiovascular disease (CVD) risk. However, their comparative effectiveness in people with HIV (PWH) is not well examined. This study evaluated the comparative effectiveness of ACEIs and ARBs head-to-head and versus no antihypertensive treatment in preventing primary CVD.
Methods:
Using a target trial emulation framework and data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), we estimated observational analogs of intention-to-treat (ITT) and per-protocol (PP) effects of antihypertensive treatments in preventing primary CVD (myocardial infarction, non-MI coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease, cardiovascular death) among hypertensive PWH, with subgroup analyses for Black and White PWH.
Results:
Compared with no antihypertensive treatment, ACEIs and ARBs were both associated with lower CVD risk in PWH, with similar effect sizes in ITT and PP analyses (ACEI ITT adjusted hazard ratio (HR): 0.79, 95% CI [0.70-0.89]; ACEI PP: 0.71 [0.55-0.90]; ARB ITT: 0.87 [0.65-1.16]; ARB PP: 0.37 [0.18-0.76]). Race-stratified ITT and PP analyses suggested somewhat greater risk reductions in White than Black PWH, although differences were not statistically significant. In head-to-head comparisons, ACEIs and ARBs showed comparable effectiveness overall (ITT: 1.14 [0.84-1.55]; PP: 0.54 [0.25-1.18]), and within race strata.
Conclusions:
Our study found that both ACEIs and ARBs were effective in reducing CVD risk among PWH, with similar effectiveness observed for both medications. The analysis did not reveal statistically significant differences in effectiveness between Black and White PWH for either drug.
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