Which ACE inhibitor or ARB is best for blood pressure management?

Selecting the Best ACE Inhibitor or ARB for Blood Pressure Management

There is no single "best" ACE inhibitor or ARB for blood pressure management, as all agents within these classes have similar efficacy for hypertension control, but medication selection should be based on specific patient factors including comorbidities, tolerability profile, and dosing convenience.

Efficacy of ACE Inhibitors and ARBs

Both ACE inhibitors and ARBs are first-line agents for hypertension management with similar blood pressure-lowering efficacy:

• Multiple guidelines recommend either ACE inhibitors or ARBs as initial therapy for hypertension, especially in patients with diabetes, chronic kidney disease, or cardiovascular disease 1
• Recent evidence suggests ARBs may have comparable efficacy to ACE inhibitors but with improved tolerability 2
• Both medication classes effectively reduce cardiovascular events and mortality when used for hypertension management 1

Factors to Consider When Selecting Between ACE Inhibitors and ARBs

Tolerability Profile

• ARBs have fewer bradykinin-mediated side effects (cough, angioedema) compared to ACE inhibitors 2
• ACE inhibitor-induced cough occurs in 5-20% of patients and is more common in women and Asian patients
• If a patient cannot tolerate an ACE inhibitor due to cough, an ARB should be substituted 1

Specific Comorbidities

1. Diabetic Nephropathy:

   • Both ACE inhibitors and ARBs are recommended for patients with diabetes and albuminuria/proteinuria 1
   • ARBs have particularly strong evidence in type 2 diabetes with nephropathy 1

2. Heart Failure:

   • ACE inhibitors have more extensive evidence in heart failure 3
   • ARBs (particularly valsartan) are indicated for heart failure when ACE inhibitors are not tolerated 4

3. Post-Myocardial Infarction:

   • ACE inhibitors are preferred in post-MI patients 3
   • Valsartan is specifically indicated to reduce cardiovascular mortality in patients with left ventricular dysfunction following MI 4

Specific Agent Selection Within Classes

ACE Inhibitors

When selecting a specific ACE inhibitor, consider:

1. Duration of Action:

   • Longer-acting agents (lisinopril, enalapril, ramipril) provide better 24-hour coverage with once-daily dosing 5
   • Captopril requires multiple daily doses (2-3 times daily) 1

2. Elimination Route:

   • Lisinopril is eliminated unchanged by the kidneys
   • Enalapril and ramipril undergo hepatic metabolism with renal elimination of active metabolites
   • Fosinopril has dual elimination pathways (hepatic and renal)

3. Dosing Recommendations:

   • Starting and target doses vary by agent (see table below) 1

ACE Inhibitor	Starting Dose	Target Dose
Lisinopril	10 mg daily	20-40 mg daily
Enalapril	5 mg daily	10-40 mg daily
Ramipril	2.5 mg daily	2.5-20 mg daily
Captopril	6.25-25 mg TID	25-150 mg BID-TID

ARBs

When selecting a specific ARB, consider:

1. Potency and Efficacy:

   • Olmesartan (40 mg) has been shown to be more effective than valsartan (160 mg) for blood pressure reduction and proteinuria reduction 6

2. Specific Indications:

   • Losartan is indicated for stroke prevention in patients with left ventricular hypertrophy 7
   • Valsartan has specific indications for heart failure and post-MI 4

3. Dosing Convenience:

   • Most ARBs can be administered once daily
   • Candesartan may require twice-daily dosing for some patients 1

Practical Approach to Selection

1. For uncomplicated hypertension:

   • Either an ACE inhibitor or ARB is appropriate
   • Consider an ARB if patient has history of cough with ACE inhibitors or is at higher risk for angioedema

2. For hypertension with diabetes and proteinuria:

   • Either an ACE inhibitor or ARB is recommended as first-line therapy
   • If one is not tolerated, switch to the other class 1

3. For hypertension with heart failure:

   • ACE inhibitor preferred (lisinopril, enalapril, ramipril)
   • ARB (valsartan) if ACE inhibitor not tolerated 4

Important Cautions

• Do not combine ACE inhibitors with ARBs - dual RAAS blockade increases risk of hyperkalemia, hypotension, and renal dysfunction 1, 8
• Monitor renal function and potassium levels when initiating therapy, especially in patients with chronic kidney disease 1, 3
• Dosage adjustment may be needed in renal impairment for most ACE inhibitors
• Both medication classes are contraindicated in pregnancy 7, 3