Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers: which class of drugs should be preferable for patients with cardiovascular pathology?

Cover Page


Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access

Abstract

The article presents a comparative analysis on the effectiveness of two classes of drugs — angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin II type 1 receptor blockers (ARB II) for patients with cardiovascular diseases: arterial hypertension, heart failure, coronary heart disease, ischemic brain disease. The advantage of ACE inhibitors over ARB II in reducing the risk of general and cardiac mortality, myocardial infarction, cerebral strokes, chronic heart failure, chronic kidney disease has been established. The positive effect of ACE inhibitors on the course of a new coronavirus infection is also demonstrated. The mechanisms of action of both classes of drugs are proposed for discussion, which substantiate the advantage of ACE inhibitors over ARB II from the standpoint of pathophysiology in relation to controlling major cardiovascular risks.

Full Text

Restricted Access

About the authors

Sergey V. Stolov

Saint Petersburg Institute of Medical Experts; North-Western State Medical University named after I.I. Mechnikov

Email: sv100lov@gmail.com
ORCID iD: 0000-0002-3431-1224
SPIN-code: 5492-2429

MD, Dr. Sci. (Med.), Professor

Russian Federation, 11/12 B. Sampsonievsky Ave., Saint-Petersburg, 194044; Saint-Petersburg

Konstantin A. Privalov

Saint Petersburg Institute of Medical Experts

Author for correspondence.
Email: kostus2004@list.ru
ORCID iD: 0000-0002-8917-3332
SPIN-code: 5323-5968
Russian Federation, 11/12 B. Sampsonievsky Ave., Saint-Petersburg, 194044

References

  1. Catalá-López F, Macías Saint-Gerons D, González-Bermejo D. Cardiovascular and renal outcomes of renin-angiotensin system blockade in adult patients with diabetes mellitus: a systematic review with network meta-analyses. PLOS Med. 2016;13(3):e1001971. doi: 10.1371/journal.pmed.1001971
  2. Wang K, Hu J, Luo T, et al. Effects of Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on all-cause mortality and renal outcomes in patients with diabetes and albuminuria: a systematic review and meta-analysis. Kidney Blood Press Res. 2018;43(3):768–779. doi: 10.1159/000489913
  3. Vremennye metodicheskie rekomendacii profilaktika, diagnostika i lechenie novoj koronavirusnoj infekcii (COVID-19). Versiya 12 (21.09.2021). (In Russ.)
  4. Stabil’naya ishemicheskaya bolezn’ serdca. Klinicheskie rekomendacii 2020. Rossijskoe kardiologicheskoe obshchestvo (RKO). (In Russ.). doi: 10.15829/1560-4071-2020-4076
  5. Mareev VYu, Fomin IV, Ageev FT, et al. Russian heart failure society, Russian society of cardiology. Russian scientific medical society of internal medicine guidelines for heart failure: chronic (CHF) and acute decompensated (ADHF). Diagnosis, prevention and treatment. Kardiologiya. 2018;58(65):8–158. (In Russ.). doi: 10.18087/cardio.2475
  6. Kobalava ZD, Konradi AO, Nedogoda SV, et al. Arterial hypertension in adults. Clinical guidelines 2020. Russian Journal of Cardiology. 2020;25(3):3786. (In Russ.). doi: 10.15829/1560-4071-2020-3-3786
  7. Type 2 diabetes: the management of type 2 diabetes. Clinical guideline (CG87) [Internet]. NICE. National Institute for Health and Care Excellence. Available from: http://www.nice.org.uk/guidance/cg87/resources/guidance-type-2-diabetes-pdf. Accessed: Sept 15, 2014.
  8. Caldeira D, David C, Sampaio C. Tolerability of angiotensin-receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and meta-analysis. Am J Cardiovasc Drugs. 2012;12(4):263–277. doi: 10.1007/BF03261835
  9. Strauss MH, Hall AS. Angiotensin receptor blockers may increase risk of myocardial infarction. Unraveling the ARB-MI paradox. Circulation. 2006;114(8):838–854. doi: 10.1161/CIRCULATIONAHA.105.594986
  10. Mancia G, Rea F, Ludergnani M, et al. Renin–angiotensin–aldosterone system blockers and the risk of COVID-19. N Engl J Med. 2020;382(25):2431–2440. doi: 10.1056/NEJMoa2006923
  11. Mehra MR, Desai SS, Kuy SR, et al. Cardiovascular disease, drug therapy, and mortality in COVID-19. N Engl J Med. 2020;382(25):e102. doi: 10.1056/NEJMoa2007621
  12. Caldeira D, Alarcao J, Vaz-Carneiro A, Costa J. Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis. BMJ. 2012;345:e4260. doi: 10.1136/bmj.e4260
  13. Valsartan. Opisanie preparata v spravochnike Vidal “Lekarstvennye preparaty v Rossii” [Internet]. Мoscow, 2021. (In Russ.) Available from: https://www.vidal.ru/drugs/molecule/1107. Accessed: Dec 6, 2021.
  14. Losartan. Opisanie preparata v spravochnike “Lekarstvennye preparaty v Rossii” [Internet]. Мoscow, 2021. (In Russ.) Available from: https://www.vidal.ru/drugs/molecule/619. Accessed: Dec 6, 2021.
  15. Zheng SL, Roddick AJ, Ayis S. Effects of aliskiren on mortality, cardiovascular outcomes and adverse events in patients with diabetes and cardiovascular disease or risk: A systematic review and meta-analysis of 13,395 patients. Diab Vasc Dis Res. 2017;14(5):400–406. doi: 10.1177/1479164117715854
  16. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851– 860. doi: 10.1056/NEJMoa011303
  17. Berl T, Hunsicker LG, Lewis JB, et al. cardiovascular outcomes in the irbesartan diabetic nephropathy trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med. 2003;138(7):542–549. doi: 10.7326/0003-4819-138-7-200304010-00010
  18. Papademetriou V, Farsang C, Elmfeldt D, et al. Stroke prevention with the angiotensin II type 1-receptor blocker candesartan in elderly patients with isolated systolic hypertension: the Study on Cognition and Prognosis in the Elderly (SCOPE). J Am Coll Cardiol. 2004;44(6):1175–1180. doi: 10.1016/j.jacc.2004.06.034
  19. Verma S, Strauss M. Angiotensin receptor blockers and myocardial infarction. BMJ. 2004;329(7477):1248–1249. doi: 10.1136/bmj.329.7477.1248
  20. Strauss MH, Hall AS. Angiotensin receptor blockers do not reduce risk of myocardial infarction, cardiovascular death, or total mortality: further evidence for the ARB-MI paradox. Circulation. 2017;135(22):2088–2090. doi: 10.1161/CIRCULATIONAHA.117.026112
  21. Turnbull F, Neal B, Algert C, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med. 2005;165(12):1410–1419. doi: 10.1001/archinte.165.12.1410
  22. McDonald MA, Simpson SH, Ezekowitz JA, et al. Angiotensin receptor blockers and risk of myocardial infarction: systematic review. BMJ. 2005;331(7521):873–879. doi: 10.1136/bmj.38595.518542.3A
  23. Tsuyuki RT, McDonald MA. Angiotensin receptor blockers do not increase risk of myocardial infarction. Circulation. 2006;114(8):855–860. doi: 10.1161/CIRCULATIONAHA.105.594978
  24. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338:b1665. doi: 10.1136/bmj.b1665
  25. Sawada T, Yamada H, Dahlof B, et al. Effects of valsartan on morbidity and mortality in uncontrolled hypertensive patients with high cardiovascular risks: KYOTO HEART Study. Eur Heart J. 2009;30(20):2461–2469. doi: 10.1093/eurheartj/ehp363
  26. Messerli FH, Bangalore S, Ruschitzka F. Angiotensin receptor blockers: baseline therapy in hypertension? Eur Heart J. 2009;30(20):2427–2430. doi: 10.1093/eurheartj/ehp364
  27. Stolov SV. Inactivation of renin-angiotensin-aldosterone system. Which class of antihypertensive medicine products to prefer? Eurasian Heart Journal. 2020;(4):64–78. (In Russ.) doi: 10.38109/2225-1685-2020-4-64-78
  28. Papademetriou V, Farsang C, Elmfeldt D, et al. Stroke prevention with the angiotensin II type 1-receptor blocker candesartan in elderly patients with isolated systolic hypertension: the Study on Cognition and Prognosis in the Elderly (SCOPE). J Am Coll Cardiol. 2004;44(6):1175–1180. doi: 10.1016/j.jacc.2004.06.034
  29. Ducharme A, Swedberg K, Pfeffer MA, et al. Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Am Heart J. 2006;152(1):86–92.
  30. Mochizuki S, Dahlöf B, Shimizu M, et al. Valsartan in a Japanese population with hypertension and other cardiovascular disease (Jikei Heart Study): a randomised, open-label, blinded endpoint morbidity-mortality study. Lancet. 2007;369(9571):1431–1439. doi: 10.1016/S0140-6736(07)60669-2
  31. Strauss MH, Lonn EM, Verma S. 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' Collaboration. Eur Heart J. 2005;26(22):2351–2353. doi: 10.1093/eurheartj/ehi574
  32. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimes based on valsartan or amlodipine: the VALUE randomized trial. Lancet. 2004;363(9426):2022–2031. doi: 10.1016/S0140-6736(04)16451-9
  33. GISSI AF Investigators, Disertori M, Latini R, et al. Valsartan for prevention of recurrent atrial fibrillation. N Engl J Med. 2009;360(16):1606–1617. doi: 10.1056/NEJMoa0805710
  34. Al Khalaf L, Thalib SAR. Cardiovascular outcomes in high-risk patients without heart failure treated with ARBs: a systematic review and meta-analysis. Am J Cardiovasc Drugs. 2009;9(1):29–43. doi: 10.1007/BF03256593
  35. Yusuf S, Teo K, Anderson C, et al. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial: The Telmisartan Randomised Assessment Study in ACE intolerant subjects with cardiovascular Disease (TRANSCEND) Investigators. Lancet. 2008;372(9644):1174–1183. doi: 10.1016/S0140-6736(08)61242-8
  36. ONTARGET Investigators; Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358(15):1547–1559. doi: 10.1056/NEJMoa0801317
  37. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2011;42(1):227–276. doi: 10.1161/STR.0b013e3181f7d043
  38. Brenner BM, Cooper ME, de Zeeuw D, et al. RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861–869. doi: 10.1056/NEJMoa011161
  39. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851–860.
  40. Khatib R. ACE inhibition for the prevention of myocardial infarction – 10 Seminal Papers. Dialogues in Cardiovascular Medicine. 2014;19(3):215.
  41. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541–2619. doi: 10.1093/eurheartj/ehu278
  42. van Vark LC, Bertrand M, Akkerhuis KM, et al. Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin–angiotensin–aldosterone system inhibitors involving 158 998 patients. Eur Heart J. 2012;33(16):2088–2097. doi: 10.1093/eurheartj/ehs075
  43. Collet JP, Thiele H, Barbato E, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289–1367. doi: 10.1093/eurheartj/ehaa575
  44. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–2219. doi: 10.1093/eurheartj/eht151
  45. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520. doi: 10.1001/jama.2013.284427
  46. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(27):2129–2200. doi: 10.1093/eurheartj/ehw128
  47. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–177. doi: 10.1093/eurheartj/ehx393
  48. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–3104. doi: 10.1093/eurheartj/ehy339
  49. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;00:1–98.
  50. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407–477. doi: 10.1093/eurheartj/ehz425
  51. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(27):2129–2200. doi: 10.1093/eurheartj/ehw128
  52. Brugts JJ, van Vark L, Akkerhuis M, et al. Impact of renin-angiotensin system inhibitors on mortality and major cardiovascular endpoints in hypertension: a number-needed-to-treat analysis. Int J Cardiol. 2015;181:425–429. doi: 10.1016/j.ijcard.2014.11.179
  53. Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2014;63(4):878–885. doi: 10.1161/HYP.0000000000000003
  54. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2018;71(6):1269–1324. doi: 10.1161/HYP.0000000000000066
  55. Kardiologiya: nacional’noe rukovodstvo. Ed. by E.V. Shlyakhto. 2-e izd. pererab. i dop. Moscow: GEHOTAR-Media; 2019. (In Russ.)
  56. Pilote L, Abrahamowicz M, Rodrigues E, et al. Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect? Ann Intern Med. 2004;141(2):102–112. doi: 10.7326/0003-4819-141-2-200407200-00008
  57. Braunwald E, Domanski MJ, Fowler SE, et al. Angiotensin-converting–enzyme inhibition in stable coronary artery disease. N Engl J Med. 2004;351(20):2058–2068. doi: 10.1056/NEJMoa042739
  58. Wing LMH, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin coverting enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med. 2003;348(7): 583–592. doi: 10.1056/NEJMoa021716
  59. Yui Y, Sumiyoshi T, Kodama K, et al. Comparison of nifedipine retard with angiotensin-converting enzyme inhibitors in Japanese hypertensive patients with coronary artery disease: the Japan Multicenter Investigation for Cardiovascular Diseases-B (JMIC-B) randomized trial. Hypertens Res. 2004;27(3):181–191. doi: 10.1291/hypres.27.181

Supplementary files

Supplementary Files
Action
1. Fig 1. Independent predictors of in-hospital mortality in the novel coronavirus infection. ACEI — angiotensin-converting enzyme inhibitors; COPD — chronic obstructive pulmonary disease; CI — confidence interval

Download (336KB)
Indexing metadata
2. Fig. 2. The risk of developing pneumonia, depending on the use of drugs. ACEI — angiotensin-converting enzyme inhibitors; ARBs — angiotensin II type 1 receptor blockers; RR — relative risk

Download (176KB)
Indexing metadata
3. Fig. 3. The results of the meta-analysis by M.H. Strauss and A.S. Hall, which included 11 clinical studies, showing that receiving angiotensin II type 1 receptor blockers increases the risk of myocardial infarction. ARBs II — angiotensin II type 1 receptor blockers; RR — relative risk; CI — confidence interval; MI — myocardial infarction

Download (347KB)
Indexing metadata
4. Fig. 4. Influence of drug intake on cardiovascular complications [9]: a — ACE inhibitors vs comparators (39 studies; n = 150,943); b — ARBs II vs comparators (11 studies; n = 55,050). ACE — angiotensin-converting enzyme; ARBs II — angiotensin II type 1 receptor blockers

Download (170KB)
Indexing metadata
5. Fig. 5. Results of the Kyoto Heart Study [25]. AG — arterial hypertension; ARBs — angiotensin receptor blockers

Download (158KB)
Indexing metadata
6. Fig. 6. Cumulative forest plots (bilateral, 95% confidence interval) depending on the presence of myocardial infarction and death from cardiovascular causes [34]. ARBs — angiotensin receptor blockers; OR — odds ratio

Download (230KB)
Indexing metadata
7. Fig. 7. TRANSCEND study results: no effect after taking telmisartan on the primary endpoint (cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure) in patients with intolerance to angiotensin-converting enzyme inhibitors. UR — unreliable

Download (100KB)
Indexing metadata
8. Fig. 8. PRoFESS study results: telmisartan does not contribute to the risk of recurrent stroke. UR — unreliable

Download (125KB)
Indexing metadata
9. Fig. 9. The effect of drugs on overall mortality [42]. ACEI — angiotensin-converting enzyme inhibitors; ARBs — angiotensin receptor blockers; RR — relative risk; CI — confidence interval; UR — unreliable

Download (405KB)
Indexing metadata
10. Fig. 10. Survival after acute myocardial infarction depending on the use of an angiotensin-converting enzyme inhibitor [56]

Download (214KB)
Indexing metadata

Copyright (c) 2021 Stolov S.V., Privalov K.A.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.
СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС 77 - 71733 от 08.12.2017.


This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies