ARB Superiority Over ACE Inhibitors in Coronary Heart Disease: An Alternative Viewpoint.
ARB Superiority Over ACE Inhibitors in Coronary Heart Disease: An Alternative Viewpoint.
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ARB 在冠心病治疗中优于 ACE 抑制剂：另一种观点。
DOI：
10.1002/phar.2216
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发表时间：
2019
期刊：
影响因子：
4.1
通讯作者：
Lee,Sukhyang
中科院分区：
文献类型：
--
作者：
Smith,StevenM;Lee,Jimin;Lee,Sukhyang
最近，Pharmacotherapy发表了一项研究，显示在冠心病中，血管紧张素受体阻滞剂（ARB）与血管紧张素转换酶抑制剂（ACEIs）相比，主要不良心血管事件（MACE）减少31%，心血管死亡率减少44%。1在现代医学中，很难找到任何一种药物与积极治疗相比，可以将MACE降低三分之一，死亡率降低近一半，特别是当它们具有基本相同的药理学机制时。此外，这些发现与随机临床试验相矛盾，这些临床试验的裁定结果显示，ACE-I与ARB相比，MACE差异很小，2，3，ARB与安慰剂相比，风险仅中度降低。4，5这些意外的发现可能源于主要的设计缺陷，涉及不适当地使用“未来”信息来定义“基线”暴露。例如，研究人员排除了未暴露的人，治疗< 3个月的人，以及没有高依从性的人。鉴于抗高血压药物依从率很少超过50%，此类患者可能占最初合格队列的一半或更多。他们的不适当的排除导致显着低估的时间在风险和高估的结果发生率在两组。此外，这些标准可能差异排除更多的ACE-I比ARB用户，因为ACE-I与更多的不良反应和较低的持久性。6，7因此，ACE-I组的人-时间比ARB组被大大低估，发生率被大大高估，这与ARB获益的（错误）结果一致。
Recently, Pharmacotherapy published a study showing a 31% reduction in major adverse cardiovascular events (MACE) and 44% reduction in cardiovascular mortality, comparing angiotensin receptor blockers (ARBs) with angiotensin-converting enzyme inhibitors (ACEIs) in coronary heart disease. 1 In modern medicine, it is difficult to find any drug that reduces MACE by one-third and mortality by nearly half compared with active therapy, especially when they share essentially the same pharmacologic mechanism. Moreover, these findings contradict randomized clinical trials with adjudicated outcomes that show little difference in MACE comparing ACE-Is to ARBs, 2, 3 and only moderate risk reduction comparing ARBs to placebo. 4, 5These unexpected findings likely stem from major design flaws involving inappropriate use of “future” information to define “baseline” exposure. For example, the researchers excluded, as unexposed, anyone treated for< 3 months, and anyone without high adherence. Given that antihypertensive adherence rates rarely exceed 50%, such patients likely made up half or more of the originally eligible cohort. Their inappropriate exclusion causes significant underestimation of time-at-risk and overestimation of outcome incidence in both groups. Moreover, these criteria probably differentially excluded more ACE-I than ARB users, since ACE-Is are associated with more adverse effects and lower persistence. 6, 7 Accordingly, person-time among the ACE-I group would be more greatly underestimated, and incidence rates more greatly overestimated, than in the ARB group, consistent with a (false) finding of ARB benefit.