recent review/meta-anal of cardiovasc events/mortality in diabetic pts on ACE-I vs ARBs (see doi:10.1001/jamainternmed.2014.348). this analysis looked at 35 studies, mostly ACE-I vs placebo or active control (22 in all, 11 placebo, most of others with CCB) and ARBs vs placebo or active control (13 in all, 9 placebo). results:
–ACE-I reduced risk of all-cause mortality 13% [RR 0.87 (0.78-0.98)], cardiovasc deaths 17% [0.83 (0.70-0.99)], major CV events 14% [0.86 (0.77-0.95] with MI dec 21% [0.79 (0.65-0.95)] and heart failure 19% [0.81 (0.71-0.93)]. no diff in studies if comparison to placebo or active control.
–ARBs reduced CHF 30% [0.70 (0.59-0.82)], but no significant decrease in major CV events overall and no signif decrease in either of the mortality outcomes. similar results if compared to placebo or active med. olmesartan may be a bad actor (2 studies showed increased death rates); excluding these studies, the results for ARBs showed no real difference in heterogeneity
–neither showed dec in stroke.
–ACE-I treatment effect on all-cause and cardiac mortality not vary significantly with either starting baseline blood pressure or proteinuria, or the types of ACE-I used or diabetes
so, there are clear limitations to the study: very few head-to-head comparisons; no standardization in dosages, A1c levels, blood pressure targets; different background therapies; different primary endpoints of the studies. but this study does suggest that there may be non-equivalences between ACE-I and ARB (most of us use ACE-I first, largely because of Prior Authorization Phobia, then ARB if not tolerated — considering them pretty equivalent in that they both block the renin-angiotensin system but through different mechanisms.) so, this study mostly supports what we are already doing, which in the local Boston culture is using mostly lisinopril as first-line med in diabetics (though data for ACE-I considerably less compelling in diabetics without microalbuminuria).
geoff