ACE inhibitors (ACEIs) may warrant consideration as a first-line therapy to prevent death and cardiovascular events in patients with diabetes mellitus, according to a meta-analysis published online March 31 in JAMA Internal Medicine. The analysis found lower rates of mortality and cardiovascular events with ACEIs, but no similar effects with ARBs.

Jun Cheng, MD, of the Medical School of Zhejiang University in Hangzhou, China, conducted a meta-analysis of randomized clinical trials that evaluated the effects of ACEIs and ARBs on all-cause mortality, cardiovascular deaths and major cardiovascular events in patients with diabetes mellitus. The primary endpoints were all-cause mortality and death from cardiovascular causes. Secondary endpoints were major cardiovascular events associated with ACEIs and ARBs.

There were 23 of 35 trials that compared ACEIs with placebo or other drugs and 13 that compared ARBs with no therapy. ACEIs significantly reduced the risk of all-cause mortality by 13 percent, cardiovascular deaths by 17 percent and major cardiovascular events by 14 percent. The risk of MI was 21 percent lower and heart failure was 19 percent lower.

While ARBs did significantly reduce the risk of heart failure (relative risk [RR] 0.70), they did not significantly affect all-cause mortality (RR 0.94), cardiovascular death (RR 1.21) and major cardiovascular events (RR 0.94). Neither drug class was associated with a decreased risk of stroke.

They acknowledged that their study’s limitations included the indirect nature of the comparison between the drug classes as well as numerous differences between the study populations. They also noted that their meta-analysis cannot confirm that ACEIs are superior to ARBs, but they argued that their findings suggest that “ACEIs should be considered as first-line therapy to limit the excess mortality and morbidity in this population.”