title: Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and the risk of major adverse cardiac events in patients with diabetes and prior stroke: a nationwide study.
abstract: OBJECTIVE
  Renin-angiotensin-aldosterone system blockers are the preferred antihypertensive medications in patients with diabetes and prior stroke. This study aimed to compare the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in terms of major adverse cardiac events (MACEs) in patients with diabetes who survived ischemic stroke.
  
  
  METHODS
  We conducted an observational, nationwide, propensity score-matched cohort study using Taiwan's National Health Insurance Research Database. Patients aged at least 20 years with type 2 diabetes who initiated ACEI (n = 15,959) or ARB (n = 23,929) use within 90 days after discharge for first ischemic stroke between January 2000 and December 2011 were allocated to ACEI and ARB groups, respectively. The primary outcomes were MACEs (myocardial infarction, ischemic stroke, and cardiovascular mortality). The secondary outcomes were hospitalization for acute kidney injury and hyperkalemia. Intention-to-treat and as-treated models were used.
  
  
  RESULTS
  Intention-to-treat analysis showed no significant difference between the ACEI and ARB groups in the outcomes of MACEs [hazard ratio (HR), 0.99; 95% confidence interval (CI), 0.95-1.04], including ischemic stroke (HR, 1.01; 95% CI, 0.97-1.06), myocardial infarction (HR, 1.06; 95% CI, 0.95-1.18), and cardiovascular mortality (HR, 0.98; 95% CI, 0.91-1.06). As-treated analysis produced similar results. Additionally, the groups showed no difference in the risk of hospitalization for acute kidney injury or hyperkalemia.
  
  
  CONCLUSIONS
  Our study supports the hypothesis that the risks of MACEs and two additional secondary outcomes in patients with diabetes who survived ischemic stroke did not differ according to ACEI versus ARB use.
authors.affiliation: aSchool of Medicine, National Yang-Ming University, Taipei bDepartment of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan cDeran Clinic, Yilan dDivision of Endocrinology and Metabolism, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch eDepartment of Anesthesiology, Wan Fang Hospital, Taipei Medical University fSchool of Medicine, Taipei Medical University, Taipei gNational Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County hDivision of Infectious Diseases, Taipei Veterans General Hospital iDivision of Nephrology, Department of Medicine, Taipei Veterans General Hospital jDivision of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan *Chia-Jen Shiha and Hung-Ta Chen contributed equally to the writing of this article. †Yung-Tai Chen and Shuo-Ming Ou contributed equally as corresponding authors to this work.
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Shih
authors.forename: Hung-Ta
authors.initials: HT
authors.lastname: Chen
authors.forename: Pei-Wen
authors.initials: PW
authors.lastname: Chao
authors.forename: Shu-Chen
authors.initials: SC
authors.lastname: Kuo
authors.forename: Szu-Yuan
authors.initials: SY
authors.lastname: Li
authors.forename: Chih-Yu
authors.initials: CY
authors.lastname: Yang
authors.forename: Der-Cherng
authors.initials: DC
authors.lastname: Tarng
authors.forename: Shuo-Ming
authors.initials: SM
authors.lastname: Ou
authors.forename: Yung-Tai
authors.initials: YT
authors.lastname: Chen
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000401:mortality*; D015331:Cohort Studies; D015897:Comorbidity; D016208:Databases, Factual; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology*; D005260:Female; D006760:Hospitalization; D006801:Humans; D006947:Hyperkalemia / Q000453:epidemiology; D006973:Hypertension / Q000188:drug therapy* / Q000453:epidemiology; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology*; D016016:Proportional Hazards Models; D012306:Risk; D020521:Stroke / Q000453:epidemiology*; D013624:Taiwan / Q000453:epidemiology
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors