Where the benefits of renin-angiotensin-aldosterone system blockade for reduction of cardiovascular risk are similar for ACE inhibitors (ACEI) and ARBs are unknown.  The answer to this question is of particular importance among diabetics, given the higher cardiovascular risk in this patient population.  In this meta-analysis, the authors examined effect of ACEI and ARBs on the incidence of mortality and cardiovascular events in diabetics. A total of 23 randomized trials comparing ACEI to placebo/no treatment/ other medications and 13 trials comparing ARBS to placebo/other medications were included. Trials with ACEI enrolled more patients with coronary artery disease than trials of ARBs. Pooled results showed that ACEI reduced the risk of all-cause mortality (relative risk [RR] 0.87; 95% CI 0.78 – 0.98) and cardiovascular events (RR 0.83; 95% CI 0.70 – 0.99). Treatment with ARBs did not influence all-cause mortality (RR 0.94; 95% CI 0.82 – 1.08) or cardiac mortality (RR 0.94; 95% CI 0.85 – 1.01). Meta-regression found the observed effects of ACEI on mortality did not differ by patient baseline characteristics or by ACEI agent.

 Conclusion: This meta-analysis found that ACEI reduced rates of all cause and cardiovascular mortality, while ARB did not.  These findings suggest that ACEI should be considered as first line therapies in diabetics.

 Summarized by Steven M. Bradley and Supriya Shore

•  Cheng J, Zhang W, Zhang X, et al. Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers on All-Cause Mortality, Cardiovascular Deaths, and Cardiovascular Events in Patients With Diabetes Mellitus: A Meta-analysis. JAMA internal medicine. May 1 2014;174(5):773-785.