Angiotensin Receptor Blockers versus Angiotensin-Converting Enzyme Inhibitors for Coronary Heart Disease: A Meta-Analysis_Chinese Journal of Evidence-Based Medicine

Authors：

LIU Xiyan ,  SU Li , YIN Yuehui , LIU Zengzhang

Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China;

Corresponding author：

SU Li, Email: xnksl@yahoo.com.cn

Keywords：

Angiotensin II receptor blocker; Angiotensin-converting enzyme inhibitor; Coronary heart disease; Cardiovascular event; Meta-analysis; Randomized controlled trial; Systematic review

DOI：

10.7507/1672-2531.20120189

Video：

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Objective 　To compare the effectiveness and safety of angiotensin receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACEI) for coronary heart disease (CHD).
Methods 　Randomized controlled trials (RCTs) on ARB vs. ACEI in treating CHD were collected in databases including MEDLINE, EMbase, BIOSIS Previews, The Cochrane Library, CBM, VIP, WanFang Data and CNKI from inception to July 2011, and the references of the included articles were also retrieved. In accordance with the Cochrane Handbook 5.0.1, two reviewers independently evaluated the quality of articles, and extracted and cross-checked the data. Then meta-analysis was performed using RevMan 5.1.1 software.
Results 　A total of 18 RCTs (17 660 cases) were included. The results of meta-analysis showed that there were no significant differences between the ARB group and the ACEI group in all-cause mortality (RR=1.04, 95%CI 0.98 to 1.11, P=0.20), cardiovascular mortality (RR=1.04, 95%CI 0.97 to 1.12, P=0.26), myocardial infarction (RR=0.98, 95%CI 0.92 to 1.05, P=0.59), hospitalization for heart failure (RR=1.14, 95%CI 0.97 to 1.32, P=0.11) and stroke (RR=0.93, 95%CI 0.80 to 1.08, P=0.34). However, the risk of adverse events causing drug discontinuation was significantly lower in the ARB group compared with the ACEI group (RR=0.77, 95%CI 0.67 to 0.89, P=0.000 3).
Conclusion 　Current evidence suggests that ARB is as effective as ACEI in reducing the risk of all-cause mortality, cardiovascular mortality, myocardial infarction, hospitalization for heart failure and stroke in patients with coronary heart disease. Moreover, it is much better in tolerance. Because of the quality limitation and sampling size of the induced studies, this conclusion still needs to be further proved by more large-scale, multicenter and perspective clinical trials.

Citation： LIU Xiyan,SU Li,YIN Yuehui,LIU Zengzhang. Angiotensin Receptor Blockers versus Angiotensin-Converting Enzyme Inhibitors for Coronary Heart Disease: A Meta-Analysis. Chinese Journal of Evidence-Based Medicine, 2012, 12(10): 1213-1222. doi: 10.7507/1672-2531.20120189 Copy

1.	Carey RM, Siragy HM. Newly recognized components of the renin–angiotensin system: potential roles in cardiovascular and renal regulation. Endocr Rev, 2003, 24(3): 261-271.
2.	Nickenig G, Harrison DG. The AT(1)-type angiotensin receptor in oxida-tive stress and atherogenesis: part I: oxidative stress and atherogenesis. Circulation, 2002, 105(3): 393-396.
3.	Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet, 2002, 360(9335): 752-760.
4.	Pfeffer MA, McMurray J, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med, 2003, 349(20): 1893-1906.
5.	McMurray J, Solomon S, Pieper K, et al. The effect of valsartan, captopril, or both on atherosclerotic events after acute myocardial infarction: an analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT). J Am Coll Cardiol, 2006, 47(4): 726-733.
6.	Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials, 1996, 17(1): 1-12.
7.	麦劲壮, 李河, 方积乾, 等. Meta分析中失安全系数的估计. 循证医学, 2006, 6(5): 297-303.
8.	Khan B, Lauten W, Khan Q, et al. Renin-angiotensin system inhibitors and coronary artery disease: a 3-year analysis of clinical outcomes in patients with coronary artery disease. European Heart Journal, 2003, 24(Abstract Supplement): 575.
9.	Maia LN, Nicolau JC, Vitola JV, et al. Prospective evaluation comparing the effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction. Am Heart J, 2003, 145(6): 27.
10.	Suzuki H, Geshi E, Nanjyo S, et al. Inhibitory effect of valsartan against progression of left ventricular dysfunction after myocardial infarction: T-VENTURE study. Circ J, 2009, 73(5): 918-924.
11.	Lauten WB, Khan QA, Rajagopalan S, et al. Usefulness of quinapril and irbesartan to improve the anti-inflammatory response of atorvastatin and aspirin in patients with coronary heart disease. Am J Cardiol, 2003, 91(9): 1116-1119.
12.	曾祥鸿, 李芸芸. 福辛普利与氯沙坦治疗冠心病心衰伴慢性阻塞性肺部疾病的长期疗效和安全性的比较. 实用医院临床杂志, 2004, 1(4): 11-12.
13.	彭晓玲, 林泽鹏, 刘强. 伴糖尿病及高血压的不稳定型心绞痛患者介入治疗后替米沙坦对血浆炎症因子水平的影响. 中国康复理论与实践, 2005, 11(6): 429-430.
14.	林泽鹏, 金光临, 张志伟. 替米沙坦对老年高血压不稳定性心绞痛患者脂联素及C反应蛋白的影响. 中华老年医学杂志, 2005, 24(8): 631-633.
15.	Suzuki H, Kusuyama T, Omori Y, et al. Inhibitory effect of candesartan cilexetil on left ventricular remodeling after myocardial infarction. Int Heart J, 2006, 47(5): 715-725.
16.	Ujiie Y, Hirosaka A, Mitsugi M, et al. Effects of angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker in combination with aspirin and cilostazol on in-stent restenosis. Int Heart J, 2006, 47(2): 173-184.
17.	陈欣, 刘欣, 陈华. 替米沙坦对陈旧前壁心肌梗死合并心衰的疗效观察. 中国医师进修杂志, 2006, 29(7): 48-49.
18.	潘莹, 张新霞, 李松. 培哚普利及缬沙坦预防冠状动脉支架内再狭窄. 岭南心血管病杂志, 2007, 13(4): 264-266.
19.	邓金龙, 吴隐雄, 赵毅兰. 培哚普利和氯沙坦治疗心肌梗死抑制心肌重构的前瞻性随机对比研究. 中国医药导刊, 2008, 10(1): 85-89.
20.	Tani S, Nagao K, Anazawa T, et al. Effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction: a possible mechanism of prevention of cardiac events by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk myocardial infarction. Inter Med, 2009, 48(11): 877-882.
21.	Montalescot G, Drexler H, Gallo R, et al. Effect of irbesartan and enalapril in non-ST elevation acute coronary syndrome: results of the randomized, double-blind ARCHIPELAGO study. European Heart Journal, 2009, 30(22): 2733-2741.
22.	Marinsek M, Sinkovic A. A randomized trial comparing the effect of ramipril and losartan in survivors of ST-elevation myocardial infarction. The Journal of International Medical Research, 2009, 37(5): 1577-1587.
23.	Yokota T, Osanai T, Hanada K, et al. Effects of telmisartan on markers of ventricular remodeling in patients with acute myocardial infarction: comparison with enalapril. Heart Vessels, 2010, 25(6): 460-468.
24.	The ONTARGET Investigators. Telmisartan, Ramipril, or both in patients at high risk for vascular events. N Engl J Med, 2008, 358(15): 1547-1559.
25.	Winkelmayer WC, Fischer MA, Schneeweiss S, et al. Angiotensin inhibition after myocardial infarction: does drug class matter? J Gen Intern Med, 2006, 21(12): 1242-1247.
26.	Verma S, Mamdani M, Al-Omran M, et al. Angiotensin receptor blockers vs. angiotensin converting enzyme inhibitors and acute coronary syndrome outcomes in elderly patients: a population-based cohort study (UMPIRE study results). J Am Soc Hypertens, 2007, 1(4): 286-294.
27.	Gianpaolo R, Fabio A, Claudio C, et al. Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis. Journal of Hypertension, 2008, 26(7): 1282-1288.
28.	Emmanuel EA, Yunbo K, John S, et al. Progress in Biophysics and Molecular Biology. 13th Edition. Pergamon Press: New York, 2010.
29.	Biollaz J, Brunner HR, Gavras, et al. Antihypertensive therapy with MK 421: angiotensin Ⅱ-renin relationships to evaluate efficacy of converting enzyme blockade. J Cardiovasc Pharmacol, 1982, 4(6): 966-972.
30.	Urata H, Healy B, Stevart RW, et al. Angiotensin Ⅱ-forming pathways in normal and failing human hearts. Circ Res, 1990, 66(4): 883-890.
31.	Bunier M, Brunner RH. Angiotensin II receptor antagonists. Lancet, 2000, 355(9204): 637‑645.
32.	Funke-Kaiser H, Reinemund J, Steckelings UM, et al. Adapter proteins and promoter regulation of the angiotensin AT2 receptor--implications for cardiac pathophysiology. Journal of the Renin-Angiotensin-Aldosterone System, 2010, 11(1): 7-17.
33.	Jones ES, Vinh A, McCarthy CA, et al. AT2 receptors: functional relevance in cardiovascular disease. Pharmacology & Therapeutics, 2008, 120(3): 292-316.
34.	Fogari R, Zoppi A. Antihypertensive drugs and fibrinolytic function. Am J Hypertens, 2006, 19(12): 1293-1299.
35.	Moher D, Pham B, Klassen TP, et al. Does the language of publication of reports of randomized trials influence the estimates of intervention effectiveness reported in meta-analyses? 6th Cochrane Colloquium. 1998.

1. Carey RM, Siragy HM. Newly recognized components of the renin–angiotensin system: potential roles in cardiovascular and renal regulation. Endocr Rev, 2003, 24(3): 261-271.
2. Nickenig G, Harrison DG. The AT(1)-type angiotensin receptor in oxida-tive stress and atherogenesis: part I: oxidative stress and atherogenesis. Circulation, 2002, 105(3): 393-396.
3. Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet, 2002, 360(9335): 752-760.
4. Pfeffer MA, McMurray J, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med, 2003, 349(20): 1893-1906.
5. McMurray J, Solomon S, Pieper K, et al. The effect of valsartan, captopril, or both on atherosclerotic events after acute myocardial infarction: an analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT). J Am Coll Cardiol, 2006, 47(4): 726-733.
6. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials, 1996, 17(1): 1-12.
7. 麦劲壮, 李河, 方积乾, 等. Meta分析中失安全系数的估计. 循证医学, 2006, 6(5): 297-303.
8. Khan B, Lauten W, Khan Q, et al. Renin-angiotensin system inhibitors and coronary artery disease: a 3-year analysis of clinical outcomes in patients with coronary artery disease. European Heart Journal, 2003, 24(Abstract Supplement): 575.
9. Maia LN, Nicolau JC, Vitola JV, et al. Prospective evaluation comparing the effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction. Am Heart J, 2003, 145(6): 27.
10. Suzuki H, Geshi E, Nanjyo S, et al. Inhibitory effect of valsartan against progression of left ventricular dysfunction after myocardial infarction: T-VENTURE study. Circ J, 2009, 73(5): 918-924.
11. Lauten WB, Khan QA, Rajagopalan S, et al. Usefulness of quinapril and irbesartan to improve the anti-inflammatory response of atorvastatin and aspirin in patients with coronary heart disease. Am J Cardiol, 2003, 91(9): 1116-1119.
12. 曾祥鸿, 李芸芸. 福辛普利与氯沙坦治疗冠心病心衰伴慢性阻塞性肺部疾病的长期疗效和安全性的比较. 实用医院临床杂志, 2004, 1(4): 11-12.
13. 彭晓玲, 林泽鹏, 刘强. 伴糖尿病及高血压的不稳定型心绞痛患者介入治疗后替米沙坦对血浆炎症因子水平的影响. 中国康复理论与实践, 2005, 11(6): 429-430.
14. 林泽鹏, 金光临, 张志伟. 替米沙坦对老年高血压不稳定性心绞痛患者脂联素及C反应蛋白的影响. 中华老年医学杂志, 2005, 24(8): 631-633.
15. Suzuki H, Kusuyama T, Omori Y, et al. Inhibitory effect of candesartan cilexetil on left ventricular remodeling after myocardial infarction. Int Heart J, 2006, 47(5): 715-725.
16. Ujiie Y, Hirosaka A, Mitsugi M, et al. Effects of angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker in combination with aspirin and cilostazol on in-stent restenosis. Int Heart J, 2006, 47(2): 173-184.
17. 陈欣, 刘欣, 陈华. 替米沙坦对陈旧前壁心肌梗死合并心衰的疗效观察. 中国医师进修杂志, 2006, 29(7): 48-49.
18. 潘莹, 张新霞, 李松. 培哚普利及缬沙坦预防冠状动脉支架内再狭窄. 岭南心血管病杂志, 2007, 13(4): 264-266.
19. 邓金龙, 吴隐雄, 赵毅兰. 培哚普利和氯沙坦治疗心肌梗死抑制心肌重构的前瞻性随机对比研究. 中国医药导刊, 2008, 10(1): 85-89.
20. Tani S, Nagao K, Anazawa T, et al. Effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction: a possible mechanism of prevention of cardiac events by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk myocardial infarction. Inter Med, 2009, 48(11): 877-882.
21. Montalescot G, Drexler H, Gallo R, et al. Effect of irbesartan and enalapril in non-ST elevation acute coronary syndrome: results of the randomized, double-blind ARCHIPELAGO study. European Heart Journal, 2009, 30(22): 2733-2741.
22. Marinsek M, Sinkovic A. A randomized trial comparing the effect of ramipril and losartan in survivors of ST-elevation myocardial infarction. The Journal of International Medical Research, 2009, 37(5): 1577-1587.
23. Yokota T, Osanai T, Hanada K, et al. Effects of telmisartan on markers of ventricular remodeling in patients with acute myocardial infarction: comparison with enalapril. Heart Vessels, 2010, 25(6): 460-468.
24. The ONTARGET Investigators. Telmisartan, Ramipril, or both in patients at high risk for vascular events. N Engl J Med, 2008, 358(15): 1547-1559.
25. Winkelmayer WC, Fischer MA, Schneeweiss S, et al. Angiotensin inhibition after myocardial infarction: does drug class matter? J Gen Intern Med, 2006, 21(12): 1242-1247.
26. Verma S, Mamdani M, Al-Omran M, et al. Angiotensin receptor blockers vs. angiotensin converting enzyme inhibitors and acute coronary syndrome outcomes in elderly patients: a population-based cohort study (UMPIRE study results). J Am Soc Hypertens, 2007, 1(4): 286-294.
27. Gianpaolo R, Fabio A, Claudio C, et al. Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis. Journal of Hypertension, 2008, 26(7): 1282-1288.
28. Emmanuel EA, Yunbo K, John S, et al. Progress in Biophysics and Molecular Biology. 13th Edition. Pergamon Press: New York, 2010.
29. Biollaz J, Brunner HR, Gavras, et al. Antihypertensive therapy with MK 421: angiotensin Ⅱ-renin relationships to evaluate efficacy of converting enzyme blockade. J Cardiovasc Pharmacol, 1982, 4(6): 966-972.
30. Urata H, Healy B, Stevart RW, et al. Angiotensin Ⅱ-forming pathways in normal and failing human hearts. Circ Res, 1990, 66(4): 883-890.
31. Bunier M, Brunner RH. Angiotensin II receptor antagonists. Lancet, 2000, 355(9204): 637‑645.
32. Funke-Kaiser H, Reinemund J, Steckelings UM, et al. Adapter proteins and promoter regulation of the angiotensin AT2 receptor--implications for cardiac pathophysiology. Journal of the Renin-Angiotensin-Aldosterone System, 2010, 11(1): 7-17.
33. Jones ES, Vinh A, McCarthy CA, et al. AT2 receptors: functional relevance in cardiovascular disease. Pharmacology & Therapeutics, 2008, 120(3): 292-316.
34. Fogari R, Zoppi A. Antihypertensive drugs and fibrinolytic function. Am J Hypertens, 2006, 19(12): 1293-1299.
35. Moher D, Pham B, Klassen TP, et al. Does the language of publication of reports of randomized trials influence the estimates of intervention effectiveness reported in meta-analyses? 6th Cochrane Colloquium. 1998.

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Angiotensin Receptor Blockers versus Angiotensin-Converting Enzyme Inhibitors for Coronary Heart Disease: A Meta-Analysis

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