Comparative Information
All ACE inhibitors have similar antihypertensive efficacy when equivalent doses are administered. The main differences lie with captopril, the first ACE inhibitor. Captopril has a shorter duration of action and an increased incidence of adverse effects. Captopril is also the only ACE inhibitor which is capable of passing through the blood–brain barrier, although the significance of this characteristic has not been shown to have any positive clinical effects.
In a large clinical study, one of the agents in the ACE inhibitor class, ramipril (Altace), demonstrated an ability to reduce the mortality rates of patients who suffered a myocardial infarction, and to slow the subsequent development of heart failure. This finding was made after it was discovered that regular use of ramipril reduced mortality rates even in test subjects who did not suffer from hypertension.
Some believe that ramipril's additional benefits may be shared by some or all drugs in the ACE inhibitor class. However, ramipril currently remains the only ACE inhibitor for which such effects are actually evidence-based.
A meta-analysis confirmed that ACE inhibitors are pivotal and certainly the first-line choice in hypertension treatment. This meta-analysis was based on 20 trials and a cohort of 158 998 patients, of whom 91% were hypertensive. Angiotensin-converting enzyme (ACE) inhibitors were used as the active treatment in 7 trials (n=76 615) and angiotensin receptor blocker (ARB) in 13 trials (n=82 383). Results showed that ACE inhibitors were associated with a statistically significant 10% mortality reduction: (HR 0.90; 95% CI, 0.84-0.97; P=0.004). In contrast, no significant mortality reduction was observed with ARB treatment (HR 0.99; 95% CI, 0.94-1.04; P=0.683). Interestingly, analysis of mortality reduction by different ACE inhibitors showed that perindopril-based regimens were associated with a statistically significant 13% all-cause mortality reduction. Taking into account the broad spectrum of the hypertensive population, one might expect that an effective treatment with ACE inhibitors, in particular with perindopril, would result in an important gain of lives saved.
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