Evidence builds for ARBs over ACE inhibitors for CV risk

Angiotensin receptor blockers (ARBs) offer superior protection against cardiovascular events compared to ACE inhibitors, especially in patients with established disease, new data from the REACH registry shows.

The observational Reduction of Atherothrombosis for Continued Health (REACH) registry followed more than 40,000 participants who were taking either treatment, mostly for existing cardiovascular disease but also for primary prevention in people with three or more risk factors for atherosclerosis, showed ARB use was associated with a 10% lower rate of cardiovascular events than with ACE inhibitors.

The study’s primary outcome was a composite of cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke or hospi­talisation for cardiovascular reasons during the 4-year follow-up.

Speaking to the limbic, co-author Professor Christopher Reid, co-director of the Monash Centre for Cardiovascular Research and Education in Therapeutics, said there was good evidence for both treatments, especially through blood pressure lowering, in a variety of high-risk groups.

ARBs are currently recommended as an alternative therapy for patients who can’t tolerate ACE inhibitors – the first choice therapy according to US and European guidelines.

“It’s interesting data from a large cohort of subjects that shows relative consistency in its findings across the various subgroups,” he said.

Subgroup analysis found the benefit of ARBs persisted regardless of a history of diabetes, heart failure or chronic kidney disease.

ARB use was also associated with lower all-cause mortality in secondary prevention but not primary prevention patients.

“However with the lack of randomisation, it may be that other unmeasured factors are driving the choice to prescribe ARBs over ACE inhibitors,” Professor Reid said.

“The next big advances will come from encouraging high compliance and persistence with taking these medications,” he said.

“We have good and effective drugs but many people just stop taking them. One possible management strategy for people at high risk is the poly-pill approach – just one pill once per day.”

He said the other advance would come from a better understanding of biomarkers and a precision medicine approach – knowing which patients will benefit most from which of the medications.

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