Diabetes and CVD risk during angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker treatment in hypertension: a study of 15,990 patients.

L P Hasvold,J Bodegård,S E Kjeldsen,J Sundström,M Thuresson,D Russell,J Stålhammar,N Hammar

doi:10.1038/jhh.2014.43

Abstract

Differences in clinical effectiveness between angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in the primary treatment of hypertension are unknown. The aim of this retrospective cohort study was to assess the prevention of type 2 diabetes and cardiovascular disease (CVD) in patients treated with ARBs or ACEis. Patients initiated on enalapril or candesartan treatment in 71 Swedish primary care centers between 1999 and 2007 were included. Medical records data were extracted and linked with nationwide hospital discharge and cause of death registers. The 11 725 patients initiated on enalapril and 4265 on candesartan had similar baseline characteristics. During a mean follow-up of 1.84 years, 36 482 patient-years, the risk of new diabetes onset was lower in the candesartan group (hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69–0.96, P=0.01) compared with the enalapril group. No difference between the groups was observed in CVD risk (HR 0.99, 95% CI 0.87–1.13, P=0.86). More patients discontinued treatment in the enalapril group (38.1%) vs the candesartan group (27.2%). In a clinical setting, patients initiated on candesartan treatment had a lower risk of new-onset type 2 diabetes and lower rates of drug discontinuation compared with patients initiated on enalapril. No differences in CVD risk were observed.

Highlights

The renin–angiotensin system is targeted by two of the most widely used antihypertensive medication classes: angiotensinconverting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs)
The initiation of enalapril or candesartan was followed by a substantial blood pressure reduction, with no difference in blood pressure between the two treatment groups (Figure 2)
In this comparative effectiveness study of 15 990 hypertension patients without cardiovascular disease (CVD) or diabetes in real-life primary care, initiation of enalapril or candesartan was followed by a substantial blood pressure reduction, with no difference in blood pressure between the two treatment groups during the follow-up period

Summary

Introduction

The renin–angiotensin system is targeted by two of the most widely used antihypertensive medication classes: angiotensinconverting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs). ACEis and ARBs inhibit the renin–angiotensin system differently and may differ in their preventive effects against both diabetes and cardiovascular disease (CVD). Possible explanations for this is the different effects of these medications on glucose metabolism through activation of different parts of the PPAR (peroxisome proliferator-activated receptors) system or more effective blockade of angiotensin type I receptors and the subsequent development of vascular insulin resistance and impaired endothelial nitric oxide-mediated relaxation.[6,7] no direct comparisons between ACEis and ABRs regarding risk of new-onset diabetes has previously been reported in patients with hypertension

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