We investigated the association between the use of ACEi, ARB, or non-renin–angiotensin–aldosterone system inhibitors (non-RASi) and incident cardiovascular events in an unselected nationwide hypertension cohort.

The information regarding 2,025,849 patients who underwent general health checkup between 2010 and 2011 and were on antihypertensive medication was collected. Patients were allocated into ACEi, ARB, and non-RASi groups and followed until 2019. The outcomes of interest were myocardial infarction (MI), ischemic stroke (IS), atrial fibrillation (AF), heart failure (HF), and all-cause deaths.

Patients on ACEi and ARB showed unfavorable baseline characteristics compared to those on non-RASi. After adjusting for covariates, the ACEi group showed lower risks of MI, AF, and all-cause deaths (HR (95% CI): 0.94 (0.89–0.99), 0.96 (0.92–1.00), and 0.93 (0.90–0.96), respectively), but similar risks of IS and HF (0.97 (0.92–1.01) and 1.03 (1.00–1.06), respectively), compared to the non-RASi group. Likewise, the ARB group showed decreased risks of MI, IS, AF, HF, and all-cause deaths (HR (95% CI): 0.93 (0.91–0.95), 0.88 (0.86–0.90), 0.86 (0.85–0.88), 0.94 (0.93–0.96), and 0.84 (0.83–0.85)), compared to the non-RASi group. Sensitivity analysis of patients taking a single antihypertensive medication showed similar results. In the propensity score matching (PSM) cohort, the ARB group showed similar risks of MI and decreased risks of IS, AF, HF, and all-cause deaths compared to the ACEi group.

ACEi and ARB users were associated with decreased risks of MI, IS, AF, HF, and all-cause deaths, compared to non-RASi users.