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Updated Report on Comparative Effectiveness of ACE inhibitors, ARBs, and Direct Renin Inhibitors for Patients with Essential Hypertension: Much More Data, Little New Information
Benjamin J. Powers, MD, MHS1,2,3, Remy R. Coeytaux, M.D., Ph.D.2,4,
Rowena J. Dolor, M.D., M.H.S.1,2,3, Vic Hasselblad, Ph.D.2,5, Uptal D. Patel, M.D.1,2,3, William S. Yancy, Jr., M.D., MHS1,2,3, Rebecca N. Gray, D. Phil.2, R. Julian Irvine, M.C.M.2, Amy S. Kendrick, R.N, M.S.N2, and Gillian D. Sanders, PhD2,3
1Center for Health Services Research In Primary Care, Durham VA Medical Center, Durham, NC, USA; 2Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; 3Department of Medicine, Duke University School of Medicine, Durham, NC, USA; 4Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA; 5Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA.
OBJECTIVES: 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.
DATA SOURCES: 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.
STUDY APPRAISAL AND SYNTHESIS METHODS: A standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.
RESULTS: 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...