- Email: [email protected]
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on prevention of stroke: Which one is better?
International Journal of Cardiology 223 (2016) 56–57
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on prevention of stroke: Which one is better? Lin Xiao a,1, Haichun Ouyang b,1, Qiwen Su a, Yuli Huang b,⁎ a b
Department of Internal Medicine, the Xingtan Affiliated Hospital of the First People's Hospital of Shunde, Foshan 528300, China Department of Cardiology, the First People's Hospital of Shunde, Foshan 528300, China
a r t i c l e
i n f o
Article history: Received 14 July 2016 Accepted 7 August 2016 Available online 8 August 2016
Keywords: Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Stroke Hypertension
We have read Pai's et al. [1] newly published paper with great interest, which using Taiwan's National Health Insurance claims data, found that in the “real world” practice in patients with hypertension and diabetes, those treated with angiotensin II receptor blockers (ARBs) regimen reduces 26% of stroke in contrast to the group with angiotensinconverting enzyme inhibitors (ACEIs) regimen. This study is very interesting. In this letter, we would like to discuss some views about choosing renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice. ACEIs are well accepted as a first-line regimen for patients with essential hypertension and reduce the risk of cardiovascular endpoints (especially for myocardial infarction and heart failure) and all-cause mortality above and “independent” of blood pressure lowering [2]. However, clinical studies about the effect of ARB for cardiovascular events prevention had been shown to be inconsistent [3–5]. A comprehensive meta-analysis had shown that including 20 randomized clinical trials (RCTs) with a total of 158,998 patients found that treatment with ACEIs were associated with a significant 10% reduction in all-cause mortality, whereas no mortality reduction could be demonstrated with ARBs treatment in patients with hypertension [6]. However, it should be noted that most of the included studies in this meta-analysis were not head-to-head comparison for the efficacy of ACEIs versus ARBs, and limited by variation between the studies' characteristics, such as populations features, dosages of the active and control drug [6]. ⁎ Corresponding author at: Department of Cardiology, the First People's Hospital of Shunde, Penglai Road, Daliang Town, Shunde District, Foshan 528300, China. E-mail address: [email protected] (Y. Huang). 1 The first two authors contributed equally to this work.
http://dx.doi.org/10.1016/j.ijcard.2016.08.150 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
Among cardiovascular events, stroke shows the strongest association with hypertension [7] and treatment with antihypertensive medicine can significantly reduce the incidence of stroke [8]. Pai's study [1] supports the practice that ARBs could be used, from the perspective of stroke prevention, as a first-line antihypertensive drug for patients with both hypertension and diabetes. Similar with this study, a meta-analysis of six RCTs including a total of 49,924 patients found that patients on ARBs had an 8% lower risk of stroke than those on ACEIs [9]. These findings have important clinical implications for treatment of hypertension and prevention of stroke, especially in Asian populations. First, the risks of target organs damage of hypertension are significantly different in different ethnicities. In hypertensive patients, stroke is more common in Asians while coronary artery disease is more prevalent in Westerners [7,10,11]. In RCTs, the risk of stroke is five to eight times more than coronary artery disease in patients with antihypertensive treatment [10]. These data support that in Asian patients with hypertension, effectiveness on prevention of stroke should be taken into account when choosing medicine. Second, the incidence of chronic cough caused by ACEIs is more prevalent in Asians. It had been reported that the incidence of discontinuing ACEIs due to cough is up to 30% in Asian patients [12]. In Pai's study [1], the medication noncompliance was not reported. However, it is interesting that compared with patients in the neither group (without ACEIs or ARBs), subjects in the ACEIs group had a 40% increased risk of stroke after multivariable adjustment. The underlying mechanisms why patients with ACEIs treatment had increased risk of stroke compared with those without RAAS inhibitors are unknown. We suspected that the noncompliance of medicine treatment during follow up duration may play an important role in it. Third, it should be noted that Pai's study is an observational retrospective study and cannot establish cause and effect as well as RCTs. Recently, the high-dimensional propensity score method was used in observational studies to address confounding in the baseline clinical characteristics. It had been reported that the proposed high-dimensional propensity score resulted in improved effect estimates compared with adjustment limited to predefined covariates [13,14]. We agree that RCTs with head-to-head comparisons for the efficacy of ACEIs versus ARBs are needed, however, until such RCTs done, we strongly suggest the authors to perform proposed high-dimensional propensity score analysis in such observational studies to further confirm the results. In conclusion, considering the high incidence of stroke in hypertensive patients and medication noncompliance of ACEI due to cough in
L. Xiao et al. / International Journal of Cardiology 223 (2016) 56–57
Asians, ARB could be considered as a first line antihypertensive medication for Asian patients. Competing interests None. Financial disclosures None. Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] P.Y. Pai, C.H. Muo, F.C. Sung, H.C. Ho, Y.T. Lee, Angiotensin receptor blockers (ARB) outperform angiotensin-converting enzyme (ACE) inhibitors on ischemic stroke prevention in patients with hypertension and diabetes — a real-world population study in Taiwan, Int. J. Cardiol. 215 (2016) 114–119. [2] G. Mancia, R. Fagard, K. Narkiewicz, J. Redon, A. Zanchetti, M. Bohm, et al., 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC), J. Hypertens. 31 (2013) 1281–1357. [3] M.A. Pfeffer, J.J. McMurray, E.J. Velazquez, J.L. Rouleau, L. Kober, A.P. Maggioni, et al., Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both, N. Engl. J. Med. 349 (2003) 1893–1906.
57
[4] S. Yusuf, K.K. Teo, J. Pogue, L. Dyal, I. Copland, H. Schumacher, et al., Telmisartan, ramipril, or both in patients at high risk for vascular events, N. Engl. J. Med. 358 (2008) 1547–1559. [5] J.J. Brugts, L. van Vark, M. Akkerhuis, M. Bertrand, K. Fox, J.J. Mourad, et al., Impact of renin-angiotensin system inhibitors on mortality and major cardiovascular endpoints in hypertension: a number-needed-to-treat analysis, Int. J. Cardiol. 181 (2015) 425–429. [6] L.C. van Vark, M. Bertrand, K.M. Akkerhuis, J.J. Brugts, K. Fox, J.J. Mourad, et al., Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving 158,998 patients, Eur. Heart J. 33 (2012) 2088–2097. [7] M.J. O'Donnell, D. Xavier, L. Liu, H. Zhang, S.L. Chin, P. Rao-Melacini, et al., Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study, Lancet 376 (2010) 112–123. [8] A.V. Chobanian, G.L. Bakris, H.R. Black, W.C. Cushman, L.A. Green, J.J. Izzo, et al., The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report, JAMA 289 (2003) 2560–2572. [9] G. Reboldi, F. Angeli, C. Cavallini, G. Gentile, G. Mancia, P. Verdecchia, Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis, J. Hypertens. 26 (2008) 1282–1289. [10] L.S. Liu, 2010 Chinese guidelines for the management of hypertension, Zhonghua Xin Xue Guan Bing Za Zhi 39 (2011) 579–615. [11] Y. Huang, X. Cai, C. Liu, D. Zhu, J. Hua, Y. Hu, et al., Prehypertension and the risk of coronary heart disease in Asian and Western populations: a meta-analysis, J. Am. Heart Assoc. 4 (2015). [12] L.P. Ng, P.S. Goh, Incidence of discontinuation of angiotensin-converting enzyme inhibitors due to cough, in a primary healthcare centre in Singapore, Singap. Med. J. 55 (2014) 146–149. [13] S. Schneeweiss, J.A. Rassen, R.J. Glynn, J. Avorn, H. Mogun, M.A. Brookhart, Highdimensional propensity score adjustment in studies of treatment effects using health care claims data, Epidemiology 20 (2009) 512–522. [14] T. Schuster, M. Pang, R.W. Platt, On the role of marginal confounder prevalence — implications for the high-dimensional propensity score algorithm, Pharmacoepidemiol. Drug Saf. 24 (2015) 1004–1007.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on prevention of stroke: Which one is better? Lin Xiao a,1, Haichun Ouyang b,1, Qiwen Su a, Yuli Huang b,⁎ a b
Department of Internal Medicine, the Xingtan Affiliated Hospital of the First People's Hospital of Shunde, Foshan 528300, China Department of Cardiology, the First People's Hospital of Shunde, Foshan 528300, China
a r t i c l e
i n f o
Article history: Received 14 July 2016 Accepted 7 August 2016 Available online 8 August 2016
Keywords: Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Stroke Hypertension
We have read Pai's et al. [1] newly published paper with great interest, which using Taiwan's National Health Insurance claims data, found that in the “real world” practice in patients with hypertension and diabetes, those treated with angiotensin II receptor blockers (ARBs) regimen reduces 26% of stroke in contrast to the group with angiotensinconverting enzyme inhibitors (ACEIs) regimen. This study is very interesting. In this letter, we would like to discuss some views about choosing renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice. ACEIs are well accepted as a first-line regimen for patients with essential hypertension and reduce the risk of cardiovascular endpoints (especially for myocardial infarction and heart failure) and all-cause mortality above and “independent” of blood pressure lowering [2]. However, clinical studies about the effect of ARB for cardiovascular events prevention had been shown to be inconsistent [3–5]. A comprehensive meta-analysis had shown that including 20 randomized clinical trials (RCTs) with a total of 158,998 patients found that treatment with ACEIs were associated with a significant 10% reduction in all-cause mortality, whereas no mortality reduction could be demonstrated with ARBs treatment in patients with hypertension [6]. However, it should be noted that most of the included studies in this meta-analysis were not head-to-head comparison for the efficacy of ACEIs versus ARBs, and limited by variation between the studies' characteristics, such as populations features, dosages of the active and control drug [6]. ⁎ Corresponding author at: Department of Cardiology, the First People's Hospital of Shunde, Penglai Road, Daliang Town, Shunde District, Foshan 528300, China. E-mail address: [email protected] (Y. Huang). 1 The first two authors contributed equally to this work.
http://dx.doi.org/10.1016/j.ijcard.2016.08.150 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
Among cardiovascular events, stroke shows the strongest association with hypertension [7] and treatment with antihypertensive medicine can significantly reduce the incidence of stroke [8]. Pai's study [1] supports the practice that ARBs could be used, from the perspective of stroke prevention, as a first-line antihypertensive drug for patients with both hypertension and diabetes. Similar with this study, a meta-analysis of six RCTs including a total of 49,924 patients found that patients on ARBs had an 8% lower risk of stroke than those on ACEIs [9]. These findings have important clinical implications for treatment of hypertension and prevention of stroke, especially in Asian populations. First, the risks of target organs damage of hypertension are significantly different in different ethnicities. In hypertensive patients, stroke is more common in Asians while coronary artery disease is more prevalent in Westerners [7,10,11]. In RCTs, the risk of stroke is five to eight times more than coronary artery disease in patients with antihypertensive treatment [10]. These data support that in Asian patients with hypertension, effectiveness on prevention of stroke should be taken into account when choosing medicine. Second, the incidence of chronic cough caused by ACEIs is more prevalent in Asians. It had been reported that the incidence of discontinuing ACEIs due to cough is up to 30% in Asian patients [12]. In Pai's study [1], the medication noncompliance was not reported. However, it is interesting that compared with patients in the neither group (without ACEIs or ARBs), subjects in the ACEIs group had a 40% increased risk of stroke after multivariable adjustment. The underlying mechanisms why patients with ACEIs treatment had increased risk of stroke compared with those without RAAS inhibitors are unknown. We suspected that the noncompliance of medicine treatment during follow up duration may play an important role in it. Third, it should be noted that Pai's study is an observational retrospective study and cannot establish cause and effect as well as RCTs. Recently, the high-dimensional propensity score method was used in observational studies to address confounding in the baseline clinical characteristics. It had been reported that the proposed high-dimensional propensity score resulted in improved effect estimates compared with adjustment limited to predefined covariates [13,14]. We agree that RCTs with head-to-head comparisons for the efficacy of ACEIs versus ARBs are needed, however, until such RCTs done, we strongly suggest the authors to perform proposed high-dimensional propensity score analysis in such observational studies to further confirm the results. In conclusion, considering the high incidence of stroke in hypertensive patients and medication noncompliance of ACEI due to cough in
L. Xiao et al. / International Journal of Cardiology 223 (2016) 56–57
Asians, ARB could be considered as a first line antihypertensive medication for Asian patients. Competing interests None. Financial disclosures None. Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] P.Y. Pai, C.H. Muo, F.C. Sung, H.C. Ho, Y.T. Lee, Angiotensin receptor blockers (ARB) outperform angiotensin-converting enzyme (ACE) inhibitors on ischemic stroke prevention in patients with hypertension and diabetes — a real-world population study in Taiwan, Int. J. Cardiol. 215 (2016) 114–119. [2] G. Mancia, R. Fagard, K. Narkiewicz, J. Redon, A. Zanchetti, M. Bohm, et al., 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC), J. Hypertens. 31 (2013) 1281–1357. [3] M.A. Pfeffer, J.J. McMurray, E.J. Velazquez, J.L. Rouleau, L. Kober, A.P. Maggioni, et al., Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both, N. Engl. J. Med. 349 (2003) 1893–1906.
57
[4] S. Yusuf, K.K. Teo, J. Pogue, L. Dyal, I. Copland, H. Schumacher, et al., Telmisartan, ramipril, or both in patients at high risk for vascular events, N. Engl. J. Med. 358 (2008) 1547–1559. [5] J.J. Brugts, L. van Vark, M. Akkerhuis, M. Bertrand, K. Fox, J.J. Mourad, et al., Impact of renin-angiotensin system inhibitors on mortality and major cardiovascular endpoints in hypertension: a number-needed-to-treat analysis, Int. J. Cardiol. 181 (2015) 425–429. [6] L.C. van Vark, M. Bertrand, K.M. Akkerhuis, J.J. Brugts, K. Fox, J.J. Mourad, et al., Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving 158,998 patients, Eur. Heart J. 33 (2012) 2088–2097. [7] M.J. O'Donnell, D. Xavier, L. Liu, H. Zhang, S.L. Chin, P. Rao-Melacini, et al., Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study, Lancet 376 (2010) 112–123. [8] A.V. Chobanian, G.L. Bakris, H.R. Black, W.C. Cushman, L.A. Green, J.J. Izzo, et al., The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report, JAMA 289 (2003) 2560–2572. [9] G. Reboldi, F. Angeli, C. Cavallini, G. Gentile, G. Mancia, P. Verdecchia, Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis, J. Hypertens. 26 (2008) 1282–1289. [10] L.S. Liu, 2010 Chinese guidelines for the management of hypertension, Zhonghua Xin Xue Guan Bing Za Zhi 39 (2011) 579–615. [11] Y. Huang, X. Cai, C. Liu, D. Zhu, J. Hua, Y. Hu, et al., Prehypertension and the risk of coronary heart disease in Asian and Western populations: a meta-analysis, J. Am. Heart Assoc. 4 (2015). [12] L.P. Ng, P.S. Goh, Incidence of discontinuation of angiotensin-converting enzyme inhibitors due to cough, in a primary healthcare centre in Singapore, Singap. Med. J. 55 (2014) 146–149. [13] S. Schneeweiss, J.A. Rassen, R.J. Glynn, J. Avorn, H. Mogun, M.A. Brookhart, Highdimensional propensity score adjustment in studies of treatment effects using health care claims data, Epidemiology 20 (2009) 512–522. [14] T. Schuster, M. Pang, R.W. Platt, On the role of marginal confounder prevalence — implications for the high-dimensional propensity score algorithm, Pharmacoepidemiol. Drug Saf. 24 (2015) 1004–1007.