Abstract
Objective: To evaluate the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) on risk of myocardial infarction (MI), angina & heart failure (HF) in patients with or at high-risk of cardiovascular disease (CVD). Design and method: A meta-analysis of randomized-controlled trials was performed. Bibliographic databases were searched until 31 July 2019 to identify all trials of ACEIs & ARBs versus control (placebo or active) & supported with head-to-head trials. Trials with at least 100 participants & at least one year's follow-up were eligible. Studies were excluded if they were redacted or combined ACEIs with ARBs. Outcomes were MI, angina pectoris & HF. Dichotomous data was analysed using risk ratio (RR) measure and its 95% confidence interval (CI) with random-effects model. A random-effects meta-regression analysis was performed to explore role systolic blood pressure (SBP) reduction achieved. Results: We identified 32 trials of ACEIs, 38 of ARBs compared with control & 8 direct comparison trials. Altogether, trials enrolled 299,871 patient-years of follow-up. Compared with control, ACEIs had a 16% lower MI risk (RR, 0.84; 95% CI, 0.79–0.90; p < 0.00001) & 17% lower HF (RR, 0.83; 95% CI, 0.76–0.92; p = 0.0003); while no such benefit was seen for angina (RR;1.02; 95% CI, 0.94–1.11; p = 0.63). ARBs was reduced risk of HF by 14% (RR, 0.86; 95% CI 0.81–0.91; p < 0.00001). While, no benefit was appeared with MI risk (RR,0.97; 95% CI 0.89–1.06; p = 0.55) & angina (RR, 0.99; 95% CI 0.88–1.11; p = 0.87). Trials comparing ARBs with ACEIs revealed no difference in outcomes. The meta-regression suggested that independently of BP reduction, ACEIs had a 11% lower MI (RR,0.89; 95% CI 0.81–0.98; p = 0.02) & ARBs provide a 15% reduction in HF (RR, 0.85; 95% CI 0.77–0.93; p = 0.001). Whereas, prevention of HF by ACEIs was explained mainly by SBP reduction achieved (p = 0.01). Conclusions: In patients with or at high-risk of CVD, ARBs and ACEIs reduced risk of HF. However, they did not appear to be case for angina. Moreover, ACEIs result in a further reduction of MI whereas ARBs had no such benefit. However, evidence from direct comparison trials suggests similar effects on all outcomes.
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