For older adults with type 2 diabetes (T2D), starting treatment with angiotensin-converting enzyme inhibitors (ACEIs) may offer superior cardiovascular protection compared with angiotensin II receptor blockers (ARBs), according to findings published in Cardiovascular Diabetology.
In this large-scale observational study using real-world data from the Yinzhou Regional Health Care Database in eastern China, ACEI use was associated with a modest but consistent reduction in major adverse cardiac events (MACE), including myocardial infarction, stroke, and all-cause mortality.
Background and Rationale
Patients with T2D are at significantly elevated risk for cardiovascular disease due to the interplay of hyperglycemia, insulin resistance, obesity, hypertension, and microvascular complications. Clinical guidelines emphasize lifestyle interventions and pharmacologic management—including renin-angiotensin system inhibitors—to reduce cardiovascular burden in this population.
ACEIs and ARBs are both commonly prescribed to treat hypertension, heart failure, chronic kidney disease, and other cardiovascular conditions. While both drug classes are effective, previous research has suggested ACEIs may confer greater benefits in preventing myocardial infarction and cardiovascular death, particularly among high-risk patients, including those with diabetes.
Study Design and Methods
The study evaluated 18,558 adults aged 65 years or older with T2D who were new users of either ACEIs or ARBs between January 1, 2010, and May 31, 2023. Participants were stratified by their initial treatment: 1,641 patients began treatment with ACEIs, while 16,917 initiated ARBs.
The primary endpoint was the occurrence of 3-point MACE—defined as hospitalization for myocardial infarction or stroke, or all-cause mortality. Secondary outcomes included a broader 4-point MACE measure that also included hospitalization for heart failure.
Commonly prescribed ACEIs included enalapril, benazepril, and perindopril; common ARBs included telmisartan, irbesartan, and valsartan.
Key Results
3-point MACE incidence:
ACEI group: 85 events
ARB group: 1,730 events
Incidence rates: 44 vs. 47.2 per 1,000 person-years
Adjusted hazard ratio (HR): 0.86, suggesting a 14% relative risk reduction with ACEIs
4-point MACE (including heart failure):
Adjusted HR: 0.83
Individual outcomes:
Hospitalized heart failure: HR 0.86
Stroke: HR 0.80
All-cause mortality: HR 0.87
These results suggest that ACEIs may offer a slight advantage over ARBs in reducing the risk of cardiovascular events in this older diabetic population, especially in the short term.
Clinical Implications
This study adds to the growing body of evidence favoring ACE inhibitors as first-line agents in managing cardiovascular risk among older patients with T2D. While ARBs remain a valuable alternative—especially for those who are intolerant to ACEIs—the findings underscore the potential benefits of initiating ACEIs when appropriate.
Further randomized studies may help validate these real-world results and guide optimal antihypertensive therapy for older adults with diabetes.
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