New York University School of Medicine, New York, NY.
New York University School of Medicine, New York, NY.
Mayo Clin Proc. 2016 Jan;91(1):51-60. doi: 10.1016/j.mayocp.2015.10.019.
To compare the efficacy and safety of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in patients without heart failure.
Meta-analysis of randomized trials identified using PubMed, Embase, and Cochrane Central Register of Controlled Trials searches from January 1, 1980, through April 13, 2015, of ACEis and ARBs compared with placebo or active controls and corroborated with head-to-head trials of ARBs vs ACEis. Outcomes were all-cause mortality, cardiovascular death, myocardial infarction (MI), angina, stroke, heart failure, revascularization, and new-onset diabetes.
Our search yielded 106 randomized trials that enrolled 254,301 patients. Compared with placebo, ACEis but not ARBs reduced the outcomes of all-cause mortality (ACEis vs placebo: relative risk [RR], 0.89; 95% CI, 0.80-1.00; ARBs vs placebo: RR, 1.01; 95% CI, 0.96-1.06; Pinteraction=.04), cardiovascular death (RR, 0.83; 95% CI, 0.70-0.99 and RR, 1.02; 95% CI, 0.92-1.14; Pinteraction=.05), and MI (RR, 0.83; 95% CI, 0.78-0.90 and RR, 0.93; 95% CI, 0.85-1.03; Pinteraction=.06). The meta-regression analysis revealed that the difference between ACEis and ARBs compared with placebo was due to a higher placebo event rate in the ACEis trials (most of these trials were conducted a decade earlier than the ARB trials) for the outcome of all-cause mortality (P=.001), cardiovascular death (P<.001), and MI (P=.02). Sensitivity analyses restricted to trials published after 2000 revealed similar outcomes with ACEis vs placebo and ARBs vs placebo (Pinteraction>.05). Head-to-head comparison trials of ARBs vs ACEis exhibited no difference in outcomes except for a lower risk of drug withdrawal due to adverse effects with ARBs (RR, 0.72; 95% CI, 0.65-0.81).
In patients without heart failure, evidence from placebo-controlled trials (restricted to trials after 2000), active controlled trials, and head-to-head randomized trials all suggest ARBs to be as efficacious and safe as ACEis, with the added advantage of better tolerability.
比较血管紧张素转换酶抑制剂（ACEIs）和血管紧张素受体阻滞剂（ARBs）在无心力衰竭患者中的疗效和安全性。
通过检索 PubMed、Embase 和 Cochrane 对照试验中心注册数据库，自 1980 年 1 月 1 日至 2015 年 4 月 13 日，对 ACEIs 和 ARBs 与安慰剂或阳性对照药物进行荟萃分析，并与 ARBs 与 ACEIs 的头对头试验结果进行了印证。主要终点为全因死亡率、心血管死亡率、心肌梗死（MI）、心绞痛、卒中和心力衰竭，次要终点为血运重建和新发糖尿病。
检索共得到 106 项随机试验，纳入 254301 例患者。与安慰剂相比，ACEIs 而非 ARBs 降低了全因死亡率（ACEIs 与安慰剂相比：RR，0.89；95%CI，0.80-1.00；ARBs 与安慰剂相比：RR，1.01；95%CI，0.96-1.06；P 交互=.04）、心血管死亡率（RR，0.83；95%CI，0.70-0.99 和 RR，1.02；95%CI，0.92-1.14；P 交互=.05）和 MI（RR，0.83；95%CI，0.78-0.90 和 RR，0.93；95%CI，0.85-1.03；P 交互=.06）。meta 回归分析显示，ACEIs 与 ARBs 与安慰剂相比的差异归因于 ACEIs 试验中安慰剂事件发生率更高（这些试验大多早于 ARB 试验 10 年进行），因此在全因死亡率（P=.001）、心血管死亡率（P<.001）和 MI（P=.02）结局中观察到差异。仅纳入 2000 年后发表的试验进行敏感性分析，结果显示 ACEIs 与安慰剂和 ARBs 与安慰剂的疗效仍相似（P 交互>.05）。ARBs 与 ACEIs 的头对头比较试验显示，除了 ARBs 因不良反应停药率更低（RR，0.72；95%CI，0.65-0.81）外，其他结局无差异。
在无心力衰竭的患者中，来自安慰剂对照试验（仅限于 2000 年后的试验）、阳性对照试验和头对头随机试验的证据均表明 ARBs 与 ACEIs 同样有效且安全，且耐受性更好。
