What is the best Angiotensin-Converting Enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) for blood pressure control?

Best ACE Inhibitor or ARB for Blood Pressure Control

Both ACE inhibitors and ARBs are equally effective for blood pressure control, with the choice between them primarily determined by patient-specific factors rather than differences in antihypertensive efficacy. 1

First-Line Recommendations

The American Diabetes Association and American Heart Association guidelines recommend either ACE inhibitors or ARBs as first-line agents for hypertension management, particularly in patients with:

• Diabetes
• Chronic kidney disease
• Cardiovascular disease
• Albuminuria/proteinuria 2, 1

Medication Selection Algorithm

1. Initial Assessment:

   • For patients with confirmed office-based BP ≥140/90 mmHg: Start pharmacologic therapy alongside lifestyle modifications 2
   • For patients with confirmed office-based BP ≥160/100 mmHg: Initiate two drugs or a single-pill combination 2

2. Patient-Specific Considerations:

   • Albuminuria present (UACR ≥300 mg/g): ACE inhibitor or ARB strongly recommended 2
   • Mild albuminuria (UACR 30-299 mg/g): ACE inhibitor or ARB suggested 2
   • Diabetes with nephropathy: Either class effective, with ARBs having particularly strong evidence in type 2 diabetes 1
   • Coronary artery disease: ACE inhibitor or ARB recommended 2
   • Cough with ACE inhibitor: Switch to ARB 1, 3

3. Monitoring:

   • Check serum creatinine/eGFR and potassium levels at least annually 2
   • Monitor more frequently when initiating therapy, especially in patients with CKD 1

Comparative Efficacy

• Both medication classes demonstrate equal efficacy in blood pressure reduction 1, 4
• No significant differences in clinical outcomes including mortality, cardiovascular events, myocardial infarction, heart failure, stroke, and end-stage renal disease 4
• ARBs have fewer adverse events overall compared to ACE inhibitors 4

Important Caveats

• Never combine ACE inhibitors with ARBs - dual RAAS blockade increases risk of hyperkalemia, hypotension, and renal dysfunction 2, 1
• ACE inhibitors are associated with cough (common) and angioedema (rare but serious) 3, 4
• Both medication classes can cause renal dysfunction and hyperkalemia 1, 5
• Both are contraindicated in pregnancy 2

Common Medication Options

ACE Inhibitors

• Lisinopril: Start 10 mg daily, target 20-40 mg daily 1
• Ramipril: Start 2.5 mg daily, target 2.5-20 mg daily 1
• Enalapril: Start 5 mg daily, target 10-40 mg daily 1

ARBs

• Losartan: Effective for hypertension, also indicated for stroke prevention in patients with LVH 6
• Candesartan: May require twice-daily dosing for some patients 1, 7

Multiple Drug Therapy

If blood pressure targets are not achieved with a single agent:

• Add a thiazide-like diuretic (preferably chlorthalidone or indapamide) 2
• Consider adding a calcium channel blocker if needed 2
• For patients not meeting targets on three medications (including a diuretic), consider adding a mineralocorticoid receptor antagonist 2

The choice between ACE inhibitors and ARBs should be based on individual patient factors, with ARBs being preferred in patients who cannot tolerate ACE inhibitors due to cough or angioedema.