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Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis

Reboldi, Gianpaoloa; Angeli, Fabiob; Cavallini, Claudiob; Gentile, Giorgioa; Mancia, Giuseppec; Verdecchia, Paolob

doi: 10.1097/HJH.0b013e328306ebe2
Meta-analysis

Objectives: To compare the effects of angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors on the risk of myocardial infarction, stroke, cardiovascular mortality and total mortality.

Methods: We conducted a meta-analysis of randomized comparative trials between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. Inclusion criteria were publication in peer-reviewed journals indexed in Medline, randomized comparison of angiotensin II receptor blockers vs. angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers + angiotensin-converting enzyme inhibitors vs. angiotensin-converting enzyme inhibitors, report of major complications including myocardial infarction, stroke, cardiovascular mortality or all-cause mortality; average follow-up of at least 1 year in at least 200 patients.

Results: Six trials fulfilled the inclusion criteria, for a total of 49 924 patients. In the pooled estimate, there were no significant differences between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors on the risk of myocardial infarction (odds ratio 1.01; 95% confidence interval 0.95–1.07; P = 0.75), cardiovascular mortality (odds ratio 1.03; 95% confidence interval 0.98–1.08; P = 0.23) and total mortality (odds ratio 1.03; 95% confidence interval 0.97–1.10; P = 0.20). This was the case also when the analysis involved only the comparison between angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. Overall, the risk of stroke was slightly lower with angiotensin II receptor blockers than angiotensin-converting enzyme inhibitors (odds ratio 0.92; 95% confidence interval 0.85–0.99; P = 0.037), the direct angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers comparison showing a nonsignificant trend in a similar direction. Statistical heterogeneity among trials was not significant, with a low to null inconsistency statistic, for stroke (P = 0.67), myocardial infarction (P = 0.86), cardiovascular mortality (P = 0.14) and total mortality (P = 0.12).

Conclusion: This overview suggests that angiotensin II receptor blockers are as effective as angiotensin-converting enzyme inhibitors on the risk of myocardial infarction, cardiovascular mortality and total mortality. Angiotensin II receptor blockers may be slightly more protective than angiotensin-converting enzyme inhibitors on the risk of stroke.

aDepartment of Internal Medicine, University of Perugia, Italy

bDepartment of Cardiology, Hospital ‘Santa Maria della Misericordia’, Perugia, Italy

cDepartment of Medicine, University of Milano-Bicocca, Milan, Italy

Received 16 April, 2008

Revised 28 April, 2008

Accepted 30 April, 2008

Correspondence to Paolo Verdecchia, MD, FACC, FAHA, Clinical Research Unit ‘Preventive Cardiology’, Department of Cardiology, Hospital ‘Santa Maria della Misericordia’, 06156 Perugia, Italy E-mail: verdec@tin.it

© 2008 Lippincott Williams & Wilkins, Inc.