Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
J Gen Intern Med. 2012 Jun;27(6):716-29. doi: 10.1007/s11606-011-1938-8. Epub 2011 Dec 7.
A 2007 systematic review compared angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with hypertension. Direct renin inhibitors (DRIs) have since been introduced, and significant new research has been published. We sought to update and expand the 2007 review.
We searched MEDLINE and EMBASE (through December 2010) and selected other sources for relevant English-language trials.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: We included studies that directly compared ACE inhibitors, ARBs, and/or DRIs in at least 20 total adults with essential hypertension; had at least 12 weeks of follow-up; and reported at least one outcome of interest. Ninety-seven (97) studies (36 new since 2007) directly comparing ACE inhibitors versus ARBs and three studies directly comparing DRIs to ACE inhibitor inhibitors or ARBs were included.
A standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.
In spite of substantial new evidence, none of the conclusions from the 2007 review changed. The level of evidence remains high for equivalence between ACE inhibitors and ARBs for blood pressure lowering and use as single antihypertensive agents, as well as for superiority of ARBs for short-term adverse events (primarily cough). However, the new evidence was insufficient on long-term cardiovascular outcomes, quality of life, progression of renal disease, medication adherence or persistence, rates of angioedema, and differences in key patient subgroups.
Included studies were limited by follow-up duration, protocol heterogeneity, and infrequent reporting on patient subgroups.
Evidence does not support a meaningful difference between ACE inhibitors and ARBs for any outcome except medication side effects. Few, if any, of the questions that were not answered in the 2007 report have been addressed by the 36 new studies. Future research in this area should consider areas of uncertainty and be prioritized accordingly.
2007 年的一项系统评价比较了血管紧张素转换酶（ACE）抑制剂和血管紧张素 II 受体阻滞剂（ARB）在高血压患者中的作用。自那时以来，直接肾素抑制剂（DRI）已经问世，并且发表了大量新的研究成果。我们试图更新和扩展 2007 年的综述。
我们检索了 MEDLINE 和 EMBASE（截至 2010 年 12 月），并为相关的英文试验选择了其他来源。
研究入选标准、参与者和干预措施：我们纳入了直接比较 ACE 抑制剂、ARB 和/或 DRI 在至少 20 例原发性高血压成人中的作用的研究；随访时间至少 12 周；并报告了至少一个感兴趣的结果。97 项（2007 年后有 36 项新研究）直接比较 ACE 抑制剂与 ARB 的研究和 3 项直接比较 DRI 与 ACE 抑制剂或 ARB 的研究被纳入。
使用标准方案提取研究设计、干预措施、人群特征和结局的数据；评估研究质量；并总结证据。
尽管有大量新的证据，但 2007 年综述的结论没有改变。ACE 抑制剂和 ARB 降低血压和作为单一抗高血压药物的疗效相当，以及 ARB 短期不良反应（主要是咳嗽）优于 ACE 抑制剂的证据仍然很高。然而，关于长期心血管结局、生活质量、肾脏疾病进展、药物依从性或持久性、血管紧张性水肿发生率以及关键患者亚组差异的新证据不足。
纳入的研究受到随访时间、方案异质性和患者亚组报告频率低的限制。
除药物副作用外，ACE 抑制剂和 ARB 对任何结局均无明显差异。在 2007 年报告未回答的问题中，很少有（如果有的话）可以通过 36 项新研究得到解答。该领域的未来研究应考虑不确定性的领域，并相应地确定优先级。
