Is lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) 20mg equivalent to nifedipine (calcium channel blocker) 60mg in terms of antihypertensive effects?

Lisinopril 20mg vs Nifedipine 60mg for Antihypertensive Effects

Lisinopril 20mg and nifedipine 60mg produce similar antihypertensive effects, but lisinopril may offer additional cardiovascular benefits beyond blood pressure reduction, particularly in patients with diabetes or at risk for myocardial infarction. 1, 2

Comparative Antihypertensive Efficacy

Several studies have directly compared these medications:

• A double-blind randomized trial found that lisinopril (20-80mg daily, mean dose 35mg) and nifedipine (20-80mg twice daily, mean dose 54mg) produced similar reductions in blood pressure after 12 weeks of therapy 1
• Another study showed lisinopril and nifedipine retard were equally effective in controlling essential hypertension, with lisinopril at median dose 40mg daily and nifedipine at median dose 60mg daily 3
• A larger multicenter study (136 patients) confirmed no significant difference in antihypertensive effect between lisinopril (20-80mg/day) and nifedipine (40-80mg/day) 4

However, one study demonstrated that lisinopril reduced sitting systolic and diastolic blood pressures by 6 and 5 mmHg more than slow-release nifedipine over 12 weeks of monotherapy 5

Beyond Blood Pressure: Cardiovascular Outcomes

While the antihypertensive effects may be similar, important differences exist in cardiovascular outcomes:

• Multiple trials comparing ACE inhibitors (like lisinopril) with calcium channel blockers (like nifedipine) showed that ACE inhibitors offer additional cardiovascular protection 2
• In the ABCD trial, patients on ACE inhibitors had significantly lower rates of myocardial infarction compared to those on calcium channel blockers (RR 5.5 [CI, 2.1 to 14.6]) despite similar blood pressure control 2
• The FACET study showed that despite better systolic blood pressure control with amlodipine (a calcium channel blocker), fosinopril (an ACE inhibitor) resulted in significantly fewer combined cardiovascular events 2
• The STOP-2 trial confirmed lower risk for myocardial infarction with ACE inhibitors compared to calcium channel blockers (RR 0.51 [CI, 0.28 to 0.92]) 2

Safety and Tolerability

The safety profiles differ between these medications:

• Lisinopril is generally better tolerated than nifedipine:
  • One study reported significantly fewer clinical side effects with lisinopril compared to nifedipine (21.3% vs 48.9%, p≤0.01) 4
  • Another study found adverse effects in only 13% of lisinopril patients versus 53% of nifedipine patients 3
• Common side effects:
  • Lisinopril: cough, rarely angioedema
  • Nifedipine: ankle swelling, flushing, headache, and reflex tachycardia 3

Special Considerations

Diabetes and Kidney Disease

• ACE inhibitors like lisinopril offer renoprotective benefits in patients with diabetes and are preferred in this population 2
• The ALLHAT trial showed no difference in cardiovascular outcomes between lisinopril and amlodipine (another calcium channel blocker) in patients with reduced kidney function (eGFR <60 mL/min/1.73 m²) 2

Dosing Convenience

• Lisinopril offers the advantage of once-daily dosing compared to twice-daily dosing often required with nifedipine 3, 5
• Lisinopril has a longer duration of action, with antihypertensive effects lasting at least 24 hours 6

Clinical Decision Making

When choosing between lisinopril 20mg and nifedipine 60mg:

1. For patients with diabetes or at risk for cardiovascular events, particularly myocardial infarction, lisinopril is preferred
2. For patients with a history of ACE inhibitor intolerance (cough, angioedema), nifedipine is a reasonable alternative
3. For patients who prefer once-daily dosing for better adherence, lisinopril offers an advantage
4. For patients with peripheral edema or who experience vasodilatory side effects, lisinopril may be better tolerated

In summary, while both medications provide similar blood pressure reduction at these doses, lisinopril 20mg may offer superior cardiovascular protection and better tolerability compared to nifedipine 60mg, particularly in patients with diabetes or at high risk for cardiovascular events.