Not every ARB may be equal for cardiovascular events

Design

Systematic review and random-effects network meta-analysis

Population

27 RCTs, about 702,584 patient-years, without baseline heart failure

Primary outcome

Major adverse cardiovascular events

Effect

Candesartan OR 0.79 (0.63–0.97); telmisartan OR 0.90 (0.80–0.99)

A random-effects network meta-analysis included 27 randomised trials with about 702,000 patient-years of follow-up, in patients without baseline heart failure.

Against placebo, candesartan reduced MACE (OR 0.79) and ranked highest; telmisartan showed a smaller reduction (OR 0.90). Most comparisons between individual ARBs were indirect, and the network was sparse in places.

The finding fits pharmacological differences in receptor binding and duration of action, but it is a ranking from indirect evidence. Both drugs are widely available and inexpensive in India, which makes the preference easy to act on when starting an ARB.

• When starting an ARB for hypertension, candesartan or telmisartan is a reasonable default choice.
• Do not switch a patient who is well controlled on another ARB on the strength of this analysis.
• Choose a dose with outcome-trial support rather than the lowest available strength.

Why it matters

It challenges the habit of treating ARBs as interchangeable for outcomes, not just blood pressure.

Don't overread it

The ranking rests mostly on indirect comparisons; no head-to-head trial has shown one ARB beats another.

The statistics, in plain English

SUCRA is a ranking score from 0 to 1 — higher means more likely to be the best — but it can rank drugs apart even when their intervals overlap. Telmisartan's upper bound of 0.99 sits just under 1, so that effect is marginal.

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