ACE Inhibitors vs ARBs in Hypertensive Diabetics: A systematic review of cardiovascular mortality and renal outcomes

Hypertension in individuals with diabetes markedly increases the risk of cardiovascular events and renal complications, making optimal management essential. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely prescribed as modulators of the renin–angiotensin–aldosterone system (RAAS). This systematic review examined their relative effectiveness in reducing cardiovascular mortality and preserving kidney function among hypertensive diabetic patients. Literature was searched across PubMed, Cochrane Library, and Scopus for randomized controlled trials and meta-analyses published within the last twenty years. Both ACEIs and ARBs were found to lower blood pressure effectively and delay the progression of diabetic nephropathy. ACEIs showed a modest advantage in lowering cardiovascular and all-cause mortality, while ARBs demonstrated comparable renal protective effects with better tolerability in patients intolerant to ACEIs. Evidence also suggests ARBs may provide greater benefit in advanced stages of chronic kidney disease, whereas ACEIs appear more advantageous in primary cardiovascular prevention. These findings emphasize the need for individualized treatment approaches, with ACEIs recommended as first-line therapy when tolerated, and ARBs as suitable alternatives. Further large-scale comparative trials are warranted to refine clinical decision-making and maximize therapeutic outcomes in this high-risk population.