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ACE Inhibitors and ARBs: Evaluating Their Impact on Health Outcomes
ACE Inhibitors and ARBs in COVID-19: Safety Concerns and Evidence
Concerns have been raised about the safety of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in COVID-19 patients due to the hypothesis that these medications might increase ACE2 expression, the receptor for SARS-CoV-2. However, a comprehensive review of studies in both animals and humans indicates that ACEIs and ARBs do not significantly increase ACE2 expression in humans, suggesting that these medications do not elevate the risk of COVID-19 complications. Therefore, patients on ACEIs and ARBs should continue their treatment as prescribed.
ACE Inhibitors and ARBs: Risk of Severe or Lethal COVID-19
A meta-analysis of observational studies involving nearly 10,000 hypertensive patients found no significant difference in the risk of severe or lethal COVID-19 between those treated with ACEIs or ARBs and untreated subjects. This supports the recommendation that patients should continue using these medications during the pandemic unless advised otherwise by their physicians.
ACE Inhibitors and ARBs in Diabetes Prevention
ACE inhibitors and ARBs have been shown to reduce the incidence of new-onset type 2 diabetes by 27% and 23%, respectively. This suggests that these medications could be beneficial for patients with pre-diabetic conditions, such as metabolic syndrome, hypertension, and a family history of diabetes.
Perioperative Use of ACE Inhibitors and ARBs
The decision to continue or withhold ACEIs and ARBs before noncardiac surgery has been debated. A meta-analysis found no significant difference in mortality or major cardiac events between patients who continued or withheld these medications. However, withholding ACEIs/ARBs was associated with a lower incidence of intraoperative hypotension, indicating that the decision should be individualized based on patient risk factors.
Cardiovascular Outcomes: ACE Inhibitors vs. ARBs
A network meta-analysis comparing ACE inhibitors and ARBs in high cardiovascular risk patients without heart failure found no significant differences in preventing cardiovascular death, myocardial infarction, or stroke. Both drug classes were similarly effective in reducing the risk of new-onset heart failure and diabetes.
ACE Inhibitors and ARBs in Chronic Limb Threatening Ischemia
In patients undergoing peripheral vascular interventions for chronic limb-threatening ischemia, ACE inhibitors and ARBs were associated with improved overall survival and amputation-free survival. However, there was no significant difference in limb salvage rates between the two groups.
Comparative Effectiveness in Hypertension
A large-scale observational study comparing ACE inhibitors and ARBs as first-line treatments for hypertension found no significant differences in the primary outcomes of acute myocardial infarction, heart failure, stroke, or composite cardiovascular events. However, ARBs had a better safety profile, with lower risks of angioedema, cough, and gastrointestinal bleeding, suggesting a preference for ARBs when initiating hypertension treatment.
Diabetes and Cardiovascular Events: ACE Inhibitors vs. ARBs
In patients with diabetes, ACE inhibitors were found to reduce all-cause mortality, cardiovascular mortality, and major cardiovascular events compared to placebo or other treatments. ARBs, on the other hand, did not show significant benefits in these outcomes except for reducing the risk of heart failure. This indicates a potential superiority of ACE inhibitors over ARBs in diabetic patients for reducing mortality and major cardiovascular events.
Conclusion
The evidence suggests that ACE inhibitors and ARBs are both effective in managing various health conditions, including hypertension, diabetes prevention, and cardiovascular risk reduction. While both drug classes are generally safe, ARBs may offer a better safety profile in terms of fewer side effects. Patients should continue their prescribed treatments, and decisions regarding the use of these medications should be tailored to individual patient needs and clinical scenarios.
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