Not just numbers, but years of science: Putting the ACE inhibitor—ARB meta-analyses into context

Prevention of coronary artery disease (CAD) events is an essential target in the management of hypertension. A series of meta-analyses have now provided proof of clear differences in the cardioprotection afforded by two of themostwidely prescribed antihypertensive classes: the angiotensin-converting enzyme (ACE) inhibitors and the angiotensin II receptor blockers (ARBs). These two classes of drugs have been often considered interchangeable, and ARBs have been considered to be ACE inhibitors with added value. ARBs have often been tested in hypertensive patients in noninferiority studies with comparators other than ACE inhibitors. Studies in heart failure failed to show noninferiority of ARBs versus ACE inhibitors, while only one study tested the hypothesis of noninferiority between ramipril and telmisartan [1]. More recently, ARBs have been tested in placebo-controlled studies and have failed to show superiority to placebo in reducing cardiovascular events and in some cases have raised concerns about the safety of long-term treatment with ARBs