Therapeutic benefits of ACE inhibitors and other antihypertensive drugs inpatients with type 2 diabetes

OBJECTIVE - To assess whether ACE inhibitors are superior to alternative ag ents for the prevention of cardiovascular events in patients with hypertens ion and type 2 diabetes. RESEARCH DESIGN AND METHODS - This study is a review and meta-analysis of r andomized controlled trials that included patients with type 2 diabetes and hypertension who were randomized to an ACE inhibitor or an alternative dru g, were followed for greater than or equal to 2 years, and had adjudicated cardiovascular events. RESULTS - A total of 4 trials were eligible. The Appropriate Blood Pressure Control in Diabetes (ABCD) trial (n = 470) compared enalapril with nisoldi pine, the Captopril Prevention Project (CAPPP) (n = 572) compared captopril with diuretics or beta-blockers, the Fosinopril Versus Amlodipine Cardiova scular Events Trial (FACET) (n = 380) compared fosinopril with amlodipine, and the U.K. Prospective Diabetes Study (UKPDS) (n = 758) compared captopri l with atenolol. The cumulative results of the first 3 trials showed a sign ificant benefit of ACE inhibitors compared with alternative treatments on t he outcomes of acute myocardial infarction (63% reduction, P < 0.001), card iovascular events (51% reduction, P < 0.001), and all-cause mortality (62% reduction, P = 0.010). These findings were not observed in the UKPDS. The A CE inhibitors did not appear to be superior to other agents for the outcome of stroke in any of the trials. None of the findings were explained by dif ferences in blood pressure control. CONCLUSIONS - Compared with the alternative agents tested, ACE inhibitors m ay provide a special advantage in addition to blood pressure control. The q uestion of whether atenolol is equivalent to captopril remains open. Conclu sive evidence on the comparative effects of anti-hypertensive treatments wi ll come from large prospective randomized trials.