Abstract
I read with interest the article by Choi et al in the March 2019 issue of the Journal of Cardiovascular Pharmacology and Therapeutics. Using data from the Korea Acute Myocardial Infarction Registry–National Institutes of Health Registry, the authors examined cardiovascular and all-cause mortality at 12 months among 12 481 patients with acute myocardial infarction who were prescribed an angiotensin-converting enzyme inhibitor (ACEIs; 4009) or angiotensin receptor blockers (ARB; 5910). 1 The investigators reported that after adjustment for multiple factors, ACEI therapy was associated with lower hazard ratio (HR) for cardiovascular mortality (0.562; 95% confidence interval [95% CI]: 0.420-0.753) and all-cause mortality (HR: 0.567; 95% CI: 0.451-0.713). The authors were careful to outline some of the limitations of their study including incomplete matching at enrollment, the possibility of unadjusted confounders, missing values, absence of data on adherence, and possible crossover.
As a result of the design of the study, the authors were not able to separate the blood pressure–dependent effects from blood pressure–independent effects of the ACEIs and ARBs; report on individual nonfatal events such as myocardial infarction, stroke, and heart failure; or compare the differences between the effects of ACEIs and ARBs on stroke and heart failure. Also, an important consideration is that the adverse effect profile, including the rare, but potentially fatal angioedema, is more benign for ARBs than for ACEIs. 2
The blood pressure–dependent and blood pressure–independent effects of agents that inhibit the renin–angiotensin system were published by the Blood Pressure Lowering Treatment Trialists’ Collaboration. 3 In this analysis of 26 large-scale randomized trials including 146 838 individuals with high blood pressure or an elevated risk of cardiovascular disease, there were 22 666 major cardiovascular events. Angiotensin-converting enzyme inhibitors were associated with lower rate of coronary heart disease events than ARBs, while there was no such difference for stroke and heart failure.
I would like to congratulate Dr Choi and associates on their important report and hope that the last paragraph of this letter may put it in a better perspective.
