Systematic Review Examining the Association of Angiotensin Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Prescription with Abdominal Aortic Aneurysm Growth and Events

Objective Whether angiotensin II blockade is an effective medical treatment for abdominal aortic aneurysms (AAAs) has not been established. This systematic review and meta-analysis aimed to determine the association of angiotensin converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) prescription with AAA growth and events. Data sources MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library databases were searched from their inception to 4 January 2024, with no language restrictions. Review Methods The five databases were searched for randomised control trials (RCTs) and observational studies reporting the association between ACEi or ARB prescription and AAA growth, repair, or rupture. The primary outcome was AAA growth, with secondary outcomes of AAA rupture, AAA repair, and AAA related events (rupture and repair combined). Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and with a modified Newcastle–Ottawa scale for observational studies. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Random effects models were used for meta-analyses. Results Eleven studies (two RCTs, eight observational studies, and one meta-analysis of individual patient data from seven populations) involving 58 022 patients were included. ACEi prescription was not associated with a significant reduction in AAA growth (standard mean difference 0.01 mm/year, 95% confidence interval [CI] –0.26 – 0.28; p = .93; I2 = 98%) or AAA repair (odds ratio [OR] 0.73, 95% CI 0.50 – 1.09; p = .65; I2 = 61%), but was associated with a significantly lower risk of AAA rupture (OR 0.87, 95% CI 0.81 – 0.93; p < .001; I2 = 26%) and AAA related events (OR 0.82, 95% CI 0.72 – 0.95; p = .006; I2 = 80%). ARB prescription was not associated with significantly reduced AAA growth or a lower risk of AAA related events. The two RCTs had a low risk of bias, with one observational study having low, seven moderate, and one high risk of bias. All of the findings had a very low certainty of evidence based on the GRADE analysis. Conclusion There was no association between ACEi or ARB prescription and AAA growth, but ACEi prescription was associated with a reduced risk of AAA rupture and AAA related events with very low certainty of evidence.