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Review
. 2016 Feb 11:352:i438.
doi: 10.1136/bmj.i438.

Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: systematic review and meta-analysis of randomized trials

Sripal Bangalore  1 , Robert Fakheri  2 , Bora Toklu  3 , Franz H Messerli  4
Affiliations
Review

Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: systematic review and meta-analysis of randomized trials

Sripal Bangalore et al. BMJ. .

Erratum in

Abstract

Objective: To evaluate the outcomes with use of renin angiotensin system (RAS) blockers compared with other antihypertensive agents in people with diabetes.

Design: Meta-analysis.

Data sources and study selection: PubMed, Embase, and the Cochrane central register of controlled trials databases for randomized trials of RAS blockers versus other antihypertensive agents in people with diabetes mellitus. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, and end stage renal disease.

Results: The search yielded 19 randomized controlled trials that enrolled 25,414 participants with diabetes for a total of 95,910 patient years of follow-up. When compared with other antihypertensive agents, RAS blockers were associated with a similar risk of death (relative risk 0.99, 95% confidence interval 0.93 to 1.05), cardiovascular death (1.02, 0.83 to 1.24), myocardial infarction (0.87, 0.64 to 1.18), angina pectoris (0.80, 0.58 to 1.11), stroke (1.04, 0.92 to 1.17), heart failure (0.90, 0.76 to 1.07), and revascularization (0.97, 0.77 to 1.22). There was also no difference in the hard renal outcome of end stage renal disease (0.99, 0.78 to 1.28) (power of 94% to show a 23% reduction in end stage renal disease).

Conclusions: In people with diabetes, RAS blockers are not superior to other antihypertensive drug classes such as thiazides, calcium channel blockers, and β blockers at reducing the risk of hard cardiovascular and renal endpoints. These findings support the recommendations of the guidelines of the European Society of Cardiology/European Society of Hypertension and eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure to also use other antihypertensive agents in people with diabetes but without kidney disease.

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Figures

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Fig 1 Outcomes of death with renin angiotensin system (RAS) blockers compared with other antihypertensives in people with diabetes
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Fig 2 Outcome of cardiovascular death with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 3 Outcome of myocardial infarction with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 4 Outcome of angina pectoris with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 5 Outcome of stroke with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 6 Outcome of heart failure with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 7 Outcome of revascularization with renin angiotensin system (RAS) compared with antihypertensives in people with diabetes
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Fig 8 Outcome of end stage renal disease with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 9 Outcome of drug withdrawal owing to adverse effects with renin angiotensin system (RAS) compared with other antihypertensives in people with diabetes
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Fig 10 Outcomes with renin angiotensin system (RAS) compared with calcium channel blockers in people with diabetes
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Fig 11 Outcomes with renin angiotensin system (RAS) compared with diuretics in people with diabetes
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Fig 12 Outcomes with renin angiotensin system (RAS) compared with β blockers in people with diabetes
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Comment in

  • Dtsch Med Wochenschr. 2016 Apr;141(8):527-8

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