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Association Between Angiotensin Receptor Blocker Use and Cardiovascular Outcomes Compared With Angiotensin-Converting
Jheng-Yan Wu1, Keng-Wei Lee2, Sheng-Chi Huang3
1Department of Nutrition, Chi Mei Medical Center, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Insights
Angiotensin receptor blocker (ARB) use showed a lower risk of major adverse cardiovascular events (MACE) compared to angiotensin-converting enzyme inhibitor (ACEI) use in patients with atherosclerotic cardiovascular disease (ASCVD). These real-world findings suggest potential benefits of ARBs but require further investigation.
Area of Science:
- Cardiology
- Pharmacology
- Epidemiology
Background:
- Atherosclerotic cardiovascular disease (ASCVD) affects millions globally, necessitating effective therapeutic strategies.
- Angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) are cornerstone therapies targeting the renin-angiotensin-aldosterone system.
- Real-world comparative effectiveness data for ARBs versus ACEIs in ASCVD populations are crucial for clinical decision-making.
Purpose of the Study:
- To compare the association between angiotensin receptor blocker (ARB) use and cardiovascular outcomes versus angiotensin-converting enzyme inhibitor (ACEI) use.
- To evaluate these associations in a large, real-world cohort of patients with established atherosclerotic cardiovascular disease (ASCVD).
- To assess the short-term incidence of major adverse cardiovascular events (MACE) and their components.
Main Methods:
- A retrospective cohort study utilizing the TriNetX global federated research network.
- Inclusion of adult patients (≥18 years) with established ASCVD between January 1, 2002, and August 31, 2025.
- Propensity score matching (1:1) to balance baseline characteristics between ARB and ACEI users, with 1-year MACE as the primary outcome.
Main Results:
- A total of 1,203,920 patients were included after propensity score matching.
- ARB users demonstrated a significantly lower 1-year incidence of MACE compared to ACEI users (7.0% vs 8.6%; HR 0.77).
- ARB use was associated with reduced risks of ischemic stroke, myocardial infarction, and all-cause mortality.
Conclusions:
- In a large real-world ASCVD cohort, ARB use was linked to a lower short-term risk of cardiovascular events compared to ACEI use.
- These observational findings highlight potential differences in outcomes but should not be interpreted as causal.
- Further research is warranted to confirm these associations and explore underlying mechanisms, such as treatment patterns and adherence.
Objective:
To evaluate the association between angiotensin receptor blocker (ARB) use and cardiovascular outcomes compared with angiotensin-converting enzyme inhibitor (ACEI) use in patients with atherosclerotic cardiovascular disease (ASCVD) in real-world clinical practice.
Methods:
We conducted a retrospective cohort study using the TriNetX global federated research network. Adults (≥18 years) with established ASCVD between January 1, 2002, and August 31, 2025, were included. Patients prescribed ARB were compared with those prescribed ACEI, excluding those who received both within 1 year of the index date. Propensity score matching (1:1) was performed to balance baseline demographics, comorbidities, medications, and laboratory data. The primary outcome was 1-year major adverse cardiac events (MACE) (ie, myocardial infarction, ischemic stroke, or all-cause mortality). Secondary outcomes included individual components of MACE. Skin cancer served as a negative control outcome. Hazard ratios were estimated using Cox proportional hazards models.
Results:
After matching, 1,203,920 patients were included. Compared with ACEI users, ARB users were associated with lower 1-year incidence of MACE (7.0% vs 8.6%; HR, 0.77; 95% CI, 0.76 to 0.78; P<.001). Use of ARB was also associated with lower risks of ischemic stroke (HR, 0.76; 95% CI, 0.75 to 0.78), acute myocardial infarction (HR, 0.85; 95% CI, 0.83 to 0.87), and all-cause mortality (HR, 0.73; 95% CI, 0.72 to 0.74). Findings were generally consistent across subgroups.
Conclusion:
In this large real-world cohort of patients with ASCVD, ARB use was associated with a lower short-term risk of adverse cardiovascular outcomes compared with ACEI use. These findings should be interpreted as noncausal and may reflect differences in treatment patterns, adherence, and patient characteristics rather than intrinsic pharmacologic superiority. Further studies are needed to confirm these observations.
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