What is the recommended initial treatment for patients requiring blood pressure management, specifically with regards to Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs)?

From the Guidelines

For initial blood pressure management, ACE inhibitors or ARBs are recommended as first-line treatments, particularly in patients with certain comorbidities, such as diabetes, chronic kidney disease, or heart failure with reduced ejection fraction. The choice between ACE inhibitors and ARBs depends on patient tolerance and specific comorbidities, with ACE inhibitors being generally preferred due to cost and clinical experience, while ARBs are preferred if patients develop a cough from ACE inhibitors 1.

Key Considerations

• Treatment typically begins with a low dose, such as lisinopril 10mg daily or losartan 50mg daily, with gradual titration based on blood pressure response.
• These medications effectively lower blood pressure by blocking the renin-angiotensin-aldosterone system, which regulates blood pressure through vasoconstriction and fluid retention.
• When starting these medications, kidney function and potassium levels should be monitored within 1-2 weeks, as they can cause hyperkalemia or acute kidney injury, especially in patients with renal artery stenosis.
• Patients should be advised that dizziness may occur initially as blood pressure decreases, and they should avoid potassium supplements and NSAIDs which can interact with these medications.

Monitoring and Follow-Up

• Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually in patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic 1.
• Blood pressure should be monitored regularly, with a goal of achieving systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg, while avoiding overly aggressive treatment that could lead to hypotension 1.

Combination Therapy

• Multiple-drug therapy is often required to achieve blood pressure targets, with combinations of an ACE inhibitor or ARB with a calcium channel blocker or diuretic being commonly recommended 1.
• The combination of an ACE inhibitor and an ARB is not recommended due to increased risk of end-stage renal disease and stroke 1.

From the Research

ACE Inhibitors and ARB Inhibitors for Blood Pressure Management

• ACE inhibitors and ARB inhibitors are both used to manage blood pressure, with ACE inhibitors working by blocking the conversion of angiotensin I to angiotensin II, and ARB inhibitors blocking the action of angiotensin II on its receptor 2.
• The use of combination therapy with ACE inhibitors and ARB inhibitors may be beneficial in certain patients, such as those with diabetic nephropathy, but may also increase the risk of hyperkalemia 2.
• Lisinopril, an ACE inhibitor, has been shown to be effective in lowering blood pressure in patients with essential and renovascular hypertension, and is comparable to other antihypertensive agents such as diuretics, beta blockers, and calcium-channel antagonists 3, 4.

Recommended Initial Treatment

• The recommended initial treatment for patients requiring blood pressure management is not explicitly stated in the provided studies, but guidelines suggest treating hypertension with drugs that have compelling indications in heart failure, with a target blood pressure of 130/80 mmHg 5.
• In patients with heart failure with preserved ejection fraction, the optimal treatment strategy remains unclear, and a similar treatment strategy to patients with reduced ejection fraction may be adopted 5.
• Special considerations and treatment adjustments are needed in certain patient populations, such as the elderly, patients with diabetes, chronic kidney disease, and atrial fibrillation 5, 6.

Considerations for Clinically Complex Scenarios

• The management of blood pressure in specific conditions such as heart failure, kidney diseases, or pediatric patients can be challenging, and new drugs and therapeutic approaches are being developed to address these challenges 6.
• Renal artery denervation has been introduced as an innovative therapy for patients with resistant hypertension, and may also have benefits in patients with heart failure 6.
• A tailored approach to blood pressure management is necessary for clinically complex and/or resistant patients, taking into account individual patient characteristics and comorbidities 6.