Association Between Angiotensin Receptor Blocker Use and Cardiovascular Outcomes Compared With Angiotensin-Converting Enzyme Inhibitors in Patients With Atherosclerotic Cardiovascular Disease: A Real-World Cohort Study.

Abstract

To evaluate the association between angiotensin receptor blocker (ARB) use and cardiovascular outcomes compared with angiotensin-converting enzyme inhibitor (ACEI) use in patients with atherosclerotic cardiovascular disease (ASCVD) in real-world clinical practice. We conducted a retrospective cohort study using the TriNetX global federated research network. Adults (≥18 years) with established ASCVD between January 1, 2002, and August 31, 2025, were included. Patients prescribed ARB were compared with those prescribed ACEI, excluding those who received both within one year of the index date. Propensity score matching (1:1) was performed to balance baseline demographics, comorbidities, medications, and laboratory data. The primary outcome was 1-year major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, or all-cause mortality). Secondary outcomes included individual components of MACE. Skin cancer served as a negative control outcome. Hazard ratios (HRs) were estimated using Cox proportional hazards models. After matching, 1,203,920 patients were included. Compared with ACEI users, ARB users were associated with lower 1-year incidence of MACE (7.0% vs 8.6%; HR 0.77 [95% CI, 0.76-0.78]; P<.001). ARB use was also associated with lower risks of ischemic stroke (HR 0.76 [95% CI, 0.75-0.78]), acute myocardial infarction (HR 0.85 [95% CI, 0.83-0.87]), and all-cause mortality (HR 0.73 [95% CI, 0.72-0.74]). Findings were generally consistent across subgroups. In this large real-world cohort of patients with ASCVD, ARB use was associated with a lower short-term risk of adverse cardiovascular outcomes compared with ACEI use. These findings should be interpreted as non-causal and may reflect differences in treatment patterns, adherence, and patient characteristics rather than intrinsic pharmacologic superiority. Further studies are needed to confirm these observations.