- Design
- Systematic review and random-effects network meta-analysis
- Population
- 27 randomised trials (702,584 patient-years) of ARBs in people without baseline heart failure
- Primary outcome
- Major adverse cardiovascular events, heart failure admission and death
- Effect
- MACE vs placebo: candesartan OR 0.79 (0.63–0.97); telmisartan OR 0.90 (0.80–0.99)
A network meta-analysis published on 26 October pooled 27 randomised trials, about 700,000 patient-years, comparing ARBs with placebo or each other in people without heart failure. The outcomes were major adverse cardiovascular events, heart failure admission and death.
Candesartan reduced major events against placebo (OR 0.79) and ranked highest. Telmisartan showed a smaller reduction (OR 0.90). Other ARBs did not show a clear effect in this analysis.
The usual assumption on the ward is that ARBs are interchangeable once blood pressure is controlled. This analysis suggests they may not be for outcomes. But most comparisons between individual ARBs were indirect, the network was sparse, and the analysis used trial-level data.
Where an ARB is chosen for cardiovascular protection rather than blood pressure alone, it is reasonable to prefer one with outcome trial evidence. It is not a reason to switch a patient who is stable on another.
- When starting an ARB for cardiovascular risk, consider candesartan or telmisartan, which have outcome data.
- Do not switch a patient stable on another ARB on this evidence alone.
- Blood pressure control remains the main driver of benefit, whichever ARB is used.
- Both candesartan and telmisartan are widely available and inexpensive in India.
Why it matters
It questions the habit of treating every ARB as the same drug.
Don't overread it
Most comparisons between ARBs were indirect; this does not prove the others are less effective.
The statistics, in plain English
An odds ratio of 0.79 (95% CI 0.63 to 0.97) for candesartan means about a fifth lower odds of a major event against placebo, but the upper limit is close to 1. SUCRA is a ranking score from 0 to 1; a high score shows a drug ranked well, not how large its benefit is.
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