Is the jury out? Class specific differences on coronary outcomes with ACE-inhibitors and ARBs: insight from meta-analysis and The Blood Pressure Lowering Treatment Trialists' CollaborationThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

This editorial refers to ‘Do angiotensin II receptor blockers increase the risk of myocardial infarction?’† by P. Verdecchia et al., on page 2381 Over the past year there has been fervent discussion and debate as to whether angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs) offer similar coronary vascular protection.1–3 A widely held belief is that ARBs may be used interchangeably with ACE-Is, and that each regimen would offer a similar reduction in coronary vascular outcomes; a notion that argues against the concept of an ACE-I-specific, blood pressure-independent vascular protective effect relative to ARBs. The Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC), recently presented at the European Society of Hypertension (ESH) and provides important insight into this matter.4 The BPLTTC is a prestigious group of clinical trialists' that is conducting prospectively planned meta-analysis of blood pressure lowering trials.5 At the 15th meeting of the ESH, Dr Turnbull presented the largest and most comprehensive meta-regression analysis of ACE-Is and ARBs.4 In this analysis, the reduction in systolic blood pressure was plotted against the relative risk of the pre-specified end-points of stroke, heart failure, and coronary heart disease. In this study of 21 large-scale randomized trials [16 trials with ACE-Is (AASK, ABCD (H), ABCD (N), ALLHAT, ANBP2, CAPPP, DIAB-HYCAR, EUROPA, HOPE, JMIC-B, PART-2, PEACE, PROGRESS, SCAT, STOP-2, UKPDS-HDS) and 5 trials with ARBs (IDNT-placebo and CCB, LIFE, RENAAL, SCOPE, VALUE)], involving 137 356 patients, the BPLTTC concluded that although there were no differences in risk reduction between ACE-Is and ARBs, with respect to the outcomes of stroke and heart failure, a highly statistically significant ( P =0.001) benefit of ACE-Is relative to ARBs on myocardial infarction (MI) and cardiovascular death was apparent. To our knowledge, this is the most robust data to support the notion that … *Corresponding authors. S.V. Tel: +1 416 782 0092; fax: +1 416 782 0096. M.H.S. Tel: +1 416 730 0938; fax +1 416 229 6162. E-mail addresses: subodh.verma@sympatico.ca or Dr.Marty@bellnet.ca