We found predominantly moderate quality evidence that all-cause mortality is similar when first-line RAS inhibitors are compared to other first-line antihypertensive agents .
First-line thiazides caused less HF and stroke than first-line RAS inhibitors .
Compared with first-line CCBs , first-line RAS inhibitors reduced HF but increased stroke .
The magnitude of the reduction in HF exceeded the increase in stroke .
The small differences in effect on blood pressure between the different classes of drugs did not correlate with the differences in the primary outcomes
BACKGROUND Renin-angiotensin system ( RAS ) inhibitors are widely prescribed for treatment of hypertension , especially for diabetic patients on the basis of postulated advantages for the reduction of diabetic nephropathy and cardiovascular morbidity and mortality .
Despite widespread use of angiotensin converting enzyme ( ACE ) inhibitors and angiotensin receptor blockers ( ARBs ) for hypertension in both diabetic and non-diabetic patients , the efficacy and safety of RAS inhibitors compared to other antihypertensive drug classes remains unclear .
OBJECTIVES To evaluate the benefits and harms of first-line RAS inhibitors compared to other first-line antihypertensive drugs in patients with hypertension .
Antihypertensive Effect and Tolerability of Perindopril in Indian Hypertensive and Type 2 Diabetic Patients
Abstract Objective : This study compared the antihypertensive effect and acceptability of a perindopril-based group with that of an atenolol-based  group in Indian hypertensive type 2 ( non-insulin-dependent ) diabetic patients . Design and Setting : 100 ambulant patients aged between 35 and 69 years were recruited into this monocentric , r and omised , double-blind study in two parallel groups for 1 year after a 1-month washout period on placebo . The setting was a tertiary care institution . Patients : All patients had stable , essential hypertension between 95 mm Hg and 115 mm Hg , type 2 diabetes with glycosylated haemoglobin ( HbA1c ) < 12 % , and albuminuria between 300 mg and 3.5g/24 hours . There were 50 patients per treatment group and two patient population groups were studied , intention-to-treat ( ITT ) and per- protocol ( PP ) . The former constituted all patients , whilst the latter included those without major protocol deviation and who completed the 12-month study . Interventions : The study drugs were perindopril 4 to 8 mg once daily or atenolol 50 to 100 mg once daily . In each group therapeutic adjustment was planned by doubling the dose and then by the addition of hydrochlorothiazide 25 mg daily . Nifedipine 30 to 60 mg daily was subsequently added if the desired drop in blood pressure was not obtained . The ITT group was analysed by Student ’s t-test , and a 2-way analysis of variance was performed for the PP population . Main Outcome Measures : A comparison of the control of hypertension , biochemical abnormalities , blood sugar and adverse effects was performed in the atenolol group versus the perindopril group . Results : On single-dose therapy after 1 month 17 patients ( 60 % ) had normal blood pressure [ diastolic blood pressure ( DBP ) ≤90 mm Hg ] on atenolol 50 mg daily , while 13 % ( 30.23 % ) had normal blood pressure ( DBP ≤90 mm Hg ) on perindopril 4 mg daily ( p = 0.013 ) . In the ITT group the sitting systolic blood pressure ( SBP ) decreased by 14.4 ± 22.3 mm Hg at the end of the treatment period on atenolol from 174.4 ± 17.9 mm Hg at the initial period , and the sitting SBP decreased by 21.6 ± 20.3 mm Hg at the end of perindopril treatment from an initial value of 172.1 ± 20.3 mm Hg ( probability 0.091 ) . The sitting DBP decreased by 18.6 ± 8.7 mm Hg on atenolol from 100.5 ± 4.8 mm Hg at the initial period and by 15.8 ± 9.1 mm Hg on perindopril from 100.6 ± 5.2 mm Hg ( probability 0.112 ) . Glycaemic control was similar for HbA1c fasting and postpr and ial glucose in the ITT population , while fasting glucose increased over time from 10.7 ± 4.1 to 12.0 ± 3.4 mmol/L ; p < 0.001 in the PP population in the atenolol group . Conclusions : The percentage of normalised patients ( sitting DBP ≤90 mm Hg ) was similar in both groups . Patients on perindopril monotherapy required more additional antihypertensive drugs compared with atenolol monotherapy . There was a significant increase in fasting blood sugar in the atenolol-based group ( p < 0.001 )
We found predominantly moderate quality evidence that all-cause mortality is similar when first-line RAS inhibitors are compared to other first-line antihypertensive agents .
First-line thiazides caused less HF and stroke than first-line RAS inhibitors .
Compared with first-line CCBs , first-line RAS inhibitors reduced HF but increased stroke .
The magnitude of the reduction in HF exceeded the increase in stroke .
The small differences in effect on blood pressure between the different classes of drugs did not correlate with the differences in the primary outcomes
BACKGROUND Renin-angiotensin system ( RAS ) inhibitors are widely prescribed for treatment of hypertension , especially for diabetic patients on the basis of postulated advantages for the reduction of diabetic nephropathy and cardiovascular morbidity and mortality .
Despite widespread use of angiotensin converting enzyme ( ACE ) inhibitors and angiotensin receptor blockers ( ARBs ) for hypertension in both diabetic and non-diabetic patients , the efficacy and safety of RAS inhibitors compared to other antihypertensive drug classes remains unclear .
OBJECTIVES To evaluate the benefits and harms of first-line RAS inhibitors compared to other first-line antihypertensive drugs in patients with hypertension .