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Original research article
Comparative effectiveness of ACE inhibitors and angiotensin receptor blockers in patients with prior myocardial infarction
  1. Dennis Ko1,
  2. Paymon Azizi2,
  3. Maria Koh1,
  4. Alice Chong1,
  5. Peter Austin1,
  6. Therese Stukel1 and
  7. Cynthia Jackevicius3
  1. 1Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  2. 2University of Toronto, Toronto, Ontatio, Canada
  3. 3Western University of Health Services, Pomona, California, USA
  1. Correspondence to Dr Dennis Ko; dennis.ko{at}


Objective Although ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are commonly prescribed for patients with coronary artery disease, whether these medications are similarly effective is still a subject of intense debate. Our objective was to compare the clinical effectiveness of ACEIs and ARBs in patients with prior myocardial infarction (MI).

Methods All residents older than 65 years, alive on 1 April 2012, with a prior MI were included. Propensity weighting was used to balance potentially confounding baseline covariates between the treatment groups. The primary outcome was a composite of cardiovascular death, hospitalisation for MI or unstable angina at 3 years.

Results Our cohort included 59 353 patients with MI; their mean age was 77 years and 40% were women. In the propensity-weighted cohort, the primary outcome occurred in 6.5% in the ACEI group and 5.7% in the ARB group at 1 year (HR comparing ACEI with ARB 1.14, 95% CI 1.05 to 1.23, p<0.001). At 3 years, the primary outcome occurring in 16.0% with ACEIs and 15.1% with ARBs (HR 1.07; 95% CI 1.02 to 1.12; p<0.001). A significant interaction with sex was observed, with women prescribed ACEIs having a higher hazards (HR 1.17; 95% CI 1.10 to 1.26) compared with ARBs, while no significant difference was seen among men (HR 1.00; 95% CI 0.93 to 1.06, interaction p<0.001).

Conclusions Despite previous concerns regarding ARBs, we found that they had slightly lower rates of adverse clinical cardiovascular outcomes among older patients with MI compared with ACEIs. The observed difference in clinical outcomes may be related to a sex difference in effectiveness.

  • angiotensin converting enzyme inhibitor
  • angiotensin receptor blocker
  • myocardial infarction
  • sex difference

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  • Contributors All authors contributed substantially to the manuscript, drafted the article or revised it critically for important intellectual content and gave final approval for the submission.

  • Funding This study was funded by a grant (G-14-0005977) from the Heart and Stroke Foundation (HSF) of Canada and a Foundation grant (FDN-154333) from the Canadian Institutes of Health Research.

  • Disclaimer The opinions, results and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by CIHI. The analyses, conclusions, opinions and statements expressed herein are those of the authors and not necessarily those of CIHI.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data may be obtained from a third party and are not publicly available.

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