ACE Inhibitors Beat ARBs for Cardiovascular Mortality in High-Risk Patients

This placebo-controlled meta-analysis gives anticoagulation and cardiology pharmacists a cleaner evidence base for preferring ACE inhibitors over ARBs as first-line renin-angiotensin blockade in high-risk patients without heart failure.

ACE inhibitorsangiotensin receptor blockersARBsperindoprilramipriltelmisartanRAAS inhibitorscardiovascular mortalitysecondary preventionmeta-analysishypertensioncoronary artery disease Cardiology / Anticoagulation

Background Information

ACE inhibitors outperform ARBs in reducing heart risks.

This study evaluates the differential impact of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) on cardiovascular outcomes in at-risk patients without heart failure. ACE-Is reduced cardiovascular mortality by 12% and myocardial infarction by 17% compared to placebo, while ARBs did not show similar benefits. ACE-Is demonstrated superior cardiovascular protection compared to ARBs in patients at high cardiovascular risk, suggesting a preferential use of ACE-Is for these patients. ACE inhibitors offer greater cardiovascular protection than ARBs in high-risk patients without heart failure.

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Authors: Masi S, Savarese G, Orsini N, Strauss MH

Citation: Masi S, Savarese G, Orsini N, et al. Impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on cardiovascular and non-cardiovascular outcomes in patients at high/very-high cardiovascular risk without heart failure: a systematic review and meta-analysis of randomized, double-blind, placebo-controlled trials (†). European heart journal open. 2026;6(4):oeag119. doi:10.1093/ehjopen/oeag119

Article Links: PubMed · Journal / DOI · Free Full Text (PMC)

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Executive Summary

Study Design

Patient Population

Primary Outcomes

Secondary Outcomes & Safety Profile

Pharmacist Implications

Clinical Pearls

Limitations

Controversies & Evidence Gaps

Cost & Logistics

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