ACEIs and ARBS: Should everybody with hypertension take them?

Since I became a general internist after a 17-year career in nephrology, I have utilized ACEIs and ARBs for myriad indications, including: hypertension, systolic heart failure, diabetic renal disease, chronic kidney disease (CKD), and for reductions in proteinuria. A recent article¹ in Progress in Cardiovascular Diseases made me apply evidence-based medicine to my choice of ACEIs and ARBs, especially in hypertension without other compelling indications for ACEIs/ARBs, and in so doing, to question their universal superiority compared to other therapeutic agents.¹

And now I turn that line of questioning over to you.

1. Of the following choices, which statements regarding ACEIs and ARBs are true?

A. Post-hoc analysis of the ALLHAT trial demonstrated that amlodipine, lisinopril, and chlorthalidone had similar efficacy in preventing cardiovascular events.^1,2

B. In ALLHAT, lisinopril and chlorthalidone were comparable in preventing heart failure.^1,2

C. In the SCOPE Trial, (elderly patients), when candesartan was compared to placebo for treatment of hypertension, there was no difference in the incidence of major cardiovascular events.^1,3

D. In the Second Australian Blood Pressure (ANBP2) trial, (patients aged 65-84 years with hypertension) when ACEIs were compared to diuretics, ACEIs were superior in preventing cardiovascular events or deaths.⁴

Answer and discussion>>

Answer: A and C are true

ALLHAT showed similar benefits when amlodipine, lisinopril, or chlorthalidone were used to treat hypertension with regard to cardiovascular events, but using chlorthalidone prevented heart failure more often than lisinopril. SCOPE and ANBP2 did not show any benefit in using ACEIs and ARBs versus either placebo or diuretics with regard to cardiovascular events.

2. In studies that prescribed ACEIs and/or ARBs specifically to patients with CKD, which of the following statements is accurate?

A. Use of either ACEIs or ARBS in persons with CKD reduces the risk of both kidney failure and cardiovascular events.^1,5

B. ACEIs also reduce all-cause mortality in CKD patients better than ARBs and should be first choice for this population.^1,5

Answer and discussion>>

Answer: Both options are accurate statements

As a result of the above data, KDIGO Guidelines (Kidney Disease: Improving Global Outcomes) recommend that ACEIs or ARBS should be first line therapy for persons with CKD, especially those with proteinuria.¹ JNC8 also recommends the same approach.¹

My recent attention to ACEIs and ARBs made me slightly more selective in using them. When CKD is present with hypertension, ACEIs and ARBs are the agents of choice. However, when hypertension is treated without other compelling indications for an ACEI or an ARB (systolic dysfunction, proteinuria, for example), especially in elderly patients, lowering blood pressure is the goal, and that lowering does not have to be with an ACEI or an ARB.

References

1. Bavishi C, Bangalore S, Messerli FH. Renin angiotensin aldosterone system inhibitors in hypertension: is there evidence for benefit independent of blood pressure reduction? Progr Cardiovasc Dis. (2016), doi: 10.1016/j.pcad.2016.10.002.

2. Rahman M, Pressel S, Davis BR, et al. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med. 2006;144:172-180.

3. Lithell H, Hansson L, Skoog I, et al. The Study on Cognition and Prognosis in the Elderly (SCOPE):principal results of a randomized double-blind intervention trial. J Hypertens. 2003;21:875-886.

4. Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with ACEIs and diuretics for hypertension in the elderly. N Engl J Med. 2003;348:583-592.

5. Xie X, Liu Y, Perkovic.Renin angiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: a Bayesian network meta-analysis of randomized clinical trials. Am J Kidney Dis. 2016; 67:728-741.