Which medication, lisinopril (Angiotensin-Converting Enzyme Inhibitor) or amlodipine (Calcium Channel Blocker), is more effective in lowering heart rate?

Comparison of Lisinopril and Amlodipine for Heart Rate Reduction

Amlodipine does not significantly lower heart rate, while lisinopril has minimal to no effect on heart rate in most patients. Neither medication is primarily indicated for heart rate reduction.

Mechanism of Action and Heart Rate Effects

Amlodipine (Calcium Channel Blocker)

• Acts as a peripheral arterial vasodilator by blocking calcium channels in vascular smooth muscle 1
• Does not significantly change heart rate with chronic oral administration in normotensive patients with angina 1
• May actually increase heart rate in some patients:
  • In a study of older hypertensive patients, amlodipine significantly increased ambulatory heart rate compared to baseline (24-hour HR: 70 vs. 66 bpm, p<0.001) 2
  • Higher doses of amlodipine (8.6 mg/day) were associated with greater increases in heart rate and plasma norepinephrine levels 2

Lisinopril (ACE Inhibitor)

• Inhibits angiotensin-converting enzyme, reducing angiotensin II and aldosterone 3
• Produces gradual blood pressure reduction without affecting heart rate or cardiovascular reflexes 3
• Does not significantly alter heart rate in most patients 4

Clinical Evidence

The ACC/AHA/ESC guidelines for management of atrial fibrillation clearly indicate that:

1. Beta-blockers are the most effective drug class for heart rate control, achieving specified heart rate endpoints in 70% of patients compared with 54% with calcium channel blockers 5

2. Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are effective for heart rate control, but amlodipine (a dihydropyridine CCB) is not mentioned for this purpose 5

3. Neither lisinopril nor other ACE inhibitors are recommended specifically for heart rate control 5

Comparative Studies

In a head-to-head comparison:

• Amlodipine reduced blood pressure more effectively than lisinopril (−20±2/−14±1 vs −11±3/−7±1 mm Hg) 6
• Amlodipine showed more consistent control of BP over 24 hours 6
• However, amlodipine was associated with increased ventricular ectopic beats compared to baseline, while temocapril (an ACE inhibitor similar to lisinopril) was not 2

Clinical Implications

If heart rate reduction is the primary goal:

• Neither amlodipine nor lisinopril should be the first choice
• Beta-blockers (such as metoprolol, atenolol) or non-dihydropyridine calcium channel blockers (verapamil, diltiazem) would be more appropriate 5
• Beta-blockers were the most effective drug class for rate control in the AFFIRM study 5

Important Considerations

• Amlodipine may actually increase heart rate in some patients, particularly at higher doses 2
• Lisinopril has minimal effect on heart rate but is not indicated for rate control 3
• When heart rate control is needed, guidelines recommend:
  1. Beta-blockers as first-line therapy
  2. Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as alternatives
  3. Digoxin or amiodarone in specific situations 5

For patients requiring both blood pressure and heart rate control, a beta-blocker would be a more appropriate choice than either lisinopril or amlodipine.