ACE inhibitors associated with decreased mortality in diabetics

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1. ACE-Inhibitors were significantly associated with decreased risk of all-cause mortality, cardiovascular death, myocardial infarction, and heart failure in patients with diabetes. 

2. Angiotensin II receptor blockers did not have a significant effect on all-cause mortality, cardiovascular death, or myocardial infarction in patients with diabetes. 

Evidence Rating Level: 1 (Excellent)     

Study Rundown: Patients with diabetes mellitus (DM) are at increased risk of premature death and cardiovascular (CV) events such as myocardial infarction (MI) and congestive heart failure (CHF). Previous research has demonstrated the cardiovascular benefit of using drugs that block the renin-angiotensin-aldosterone system in patients with DM. This meta-analysis aimed to assess the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockade (ARBs) on all-cause mortality, CV death, and CV events in patients with DM. ACEIs significantly reduced the risk of all-cause mortality, CV death, myocardial infarction, and heart failure. However, ARBs had no beneficial effect on these measures, except for heart failure. This study did not include trials that directly compared ACEIs to ARBs so we cannot definitively conclude that ACEIs are more effective than ARBs. Overall, this meta-analysis provides strong evidence for the cardioprotective effects of ACEIs in patients with DM.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Angiotensin-converting enzyme inhibitors reduce mortality in hypertension

In-Depth [meta-analysis]: This study included 56,444 patients with type 1 or type 2 diabetes from 35 randomized controlled trials that assessed either the effect of ACEIs or ARBs versus control therapy (active treatment, placebo, or no treatment). The primary end points included all-cause mortality and death from cardiovascular causes, and myocardial infarction (MI). ACEIs were associated with a 13% reduction in all-cause mortality (RR, 0.87; p = 0.02; 95%CI, 0.78-0.98) and a 17% reduction in CV deaths (RR, 0.83; p = 0.04; 95%CI 0.70-0.99). In addition, ACEIs were associated with a 21% decrease in risk of myocardial infarction (RR, 0.79; p = 0.01; 95%CI: 0.65-0.95) and 19% decreased risk of heart failure (RR, 0.81; p = 0.002; 95%CI: 0.71-0.93). On the other hand, ARBs were not associated with a significant decrease in risk of all-cause mortality (RR, 0.94; p = 0.39; 95%CI: 0.82-1.08) or CV deaths (RR, 1.21; p = 0.35; 95%CI: 0.81-1.80). However, ARBs were significantly associated with a 30% decreased risk of heart failure (RR, 0.70; p<0.01; 95%CI: 0.59-0.82), but had no effect on MI (RR, 0.89; p = 0.22, 95%CI: 0.74-1.07).

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