• Benjamin J Powers, Remy R Coeytaux, Rowena J Dolor, Vic Hasselblad, Uptal D Patel, William S Yancy, Rebecca N Gray, R Julian Irvine, Amy S Kendrick, and Gillian D Sanders.
• Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA. ben.powers@duke.edu
• J Gen Intern Med. 2012 Jun 1; 27 (6): 716-29.

ObjectivesA 2007 systematic review compared angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with hypertension. Direct renin inhibitors (DRIs) have since been introduced, and significant new research has been published. We sought to update and expand the 2007 review.Data SourcesWe searched MEDLINE and EMBASE (through December 2010) and selected other sources for relevant English-language trials.Study Eligibility Criteria, Participants, And InterventionsWe included studies that directly compared ACE inhibitors, ARBs, and/or DRIs in at least 20 total adults with essential hypertension; had at least 12 weeks of follow-up; and reported at least one outcome of interest. Ninety-seven (97) studies (36 new since 2007) directly comparing ACE inhibitors versus ARBs and three studies directly comparing DRIs to ACE inhibitor inhibitors or ARBs were included.Study Appraisal And Synthesis MethodsA standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.ResultsIn spite of substantial new evidence, none of the conclusions from the 2007 review changed. The level of evidence remains high for equivalence between ACE inhibitors and ARBs for blood pressure lowering and use as single antihypertensive agents, as well as for superiority of ARBs for short-term adverse events (primarily cough). However, the new evidence was insufficient on long-term cardiovascular outcomes, quality of life, progression of renal disease, medication adherence or persistence, rates of angioedema, and differences in key patient subgroups.LimitationsIncluded studies were limited by follow-up duration, protocol heterogeneity, and infrequent reporting on patient subgroups.Conclusions And Implications Of Key FindingsEvidence does not support a meaningful difference between ACE inhibitors and ARBs for any outcome except medication side effects. Few, if any, of the questions that were not answered in the 2007 report have been addressed by the 36 new studies. Future research in this area should consider areas of uncertainty and be prioritized accordingly.

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