Comparative Effectiveness Of Different Renin-Angiotensin System Blockers In Patients With Prior Stroke:a PRISMA-Compliant Network Meta-Analysis

BsckgroundAngiotensin-converting enzyme inhibitors(ACEIs)and angiotensin receptor blockers(ARBs)are major pasts of the renin-angiotensin system blockers,and they are commonly used for the patients who have already suffered from stroke.However,the abundance of ACEIs and ARBs make it difficult for doctor to choose.Objective:We performed a network meta-analysis to determine the comparative efficacy of different members within ACEIs and ARBs with respect to outcomes of(i)prevention of stroke recurrence and(ii)reduction of major vascular events,and provide more evidence to the second prevention of stroke.Methods:We searched PubMed,Cochrane Library,Embase,CNKI Data frome inception to November 1st 2018 to collect the randomized controlled trials about the association between use of ACEIs and ARBs and the stroke secondary prevention in adults.Two reviewers independently screened literature,extracted data and assessed the risk of bias of included studies.Then,Network meta-analysis was performed using Stata 15.1 software.Odds radio(OR)with 95% confidence interval(CI)was used as measure of the association between use of ACEIs and ARBs and risks of stroke recurrence and major vascular events(nonfatal stroke,nonfatal myocardial infarction,or death from cardiovascular causes).Last,put them in order based on their efficacy.Results:Six RCTs composed of 25 620 participants with previous stroke were identified.Compared with the placebo,candesartan(OR=0.36,95%CI 0.13 to 0.97)and valsartan(OR =0.19,95%CI 0.05 to 0.73)significantly reduced recurrent stroke events.Valsartan is better than telmisartan(OR=0.21,95%CI 0.05 to 0.78),ramipril(OR=0.23,95%CI 0.06 to 0.91)and perindopril(OR=0.21,95%CI 0.05 to 0.79).Both candesartan(OR=0.32,95%CI 0.15 to 0.68),valsartan(OR=0.21,95%CI 0.08 to 0.57)and ramipril(OR=0.70,95%CI 0.52 to 0.94)significantly reduced the major vascular events after stroke compared to placebo.Valsartan is better than telmisartan(OR=0.22,95%CI 0.08 to 0.61),ramipril(OR=0.30,95%CI 0.10 to 0.85)and perindopril(OR=0.22,95%CI 0.08 to 0.61).Candesartan is better than telmisartan(OR=0.34,95%CI 0.16 to 0.73)and perindopril(OR=0.33,95%CI 0.15 to 0.74).Conclusion: Our results suggest that valsartan and candesartan can reduce the stroke reccurence and major vascular events after stroke.Ramipril can reduce the major vascular event in patients with prior stroke.Valsartan might be the best option in the both outcomes.Due to limited quality and quantity of included studies,the above results should be validated by more studies.