ARBs in Athletes: Recommended Agents
For athletes with hypertension, any ARB from the class is appropriate as first-line therapy, as ARBs (along with ACE inhibitors and calcium channel blockers) are the preferred antihypertensive agents for this population—no specific ARB has been demonstrated superior for athletic performance or cardiovascular outcomes. 1
Why ARBs Are Preferred in Athletes
Calcium channel blockers and blockers of the renin-angiotensin system (ACE inhibitors and ARBs) are the drugs of choice for hypertensive endurance athletes because they avoid the performance-limiting effects of other antihypertensive classes. 1
Key Advantages for Athletes:
No impairment of exercise performance: Unlike beta-blockers and diuretics, ARBs do not reduce exercise capacity or cause detrimental hemodynamic changes during exertion 2, 3, 4
Avoid fluid and electrolyte disturbances: Critical for athletes who experience substantial salt and water losses through sweating 5
No doping concerns: Beta-blockers and diuretics are prohibited in certain sports by athletic governing bodies, whereas ARBs are not restricted 1
Preserve endothelial function: ARBs maintain vascular function important for athletic performance 5
Specific ARB Selection
The evidence does not identify a single "best" ARB for athletes. The major guidelines and research consistently recommend the ARB class as a whole without distinguishing between individual agents. 1, 2, 3, 5
Commonly Used ARBs Include:
Losartan: FDA-approved for hypertension, stroke risk reduction in patients with left ventricular hypertrophy, and diabetic nephropathy 6
Telmisartan: FDA-approved for hypertension and cardiovascular risk reduction 7
Valsartan, Olmesartan, Azilsartan: All effective for blood pressure reduction, with azilsartan showing superior systolic blood pressure lowering compared to valsartan 320 mg or olmesartan 40 mg in short-term studies 8
The choice among ARBs should be based on:
- Comorbid conditions (e.g., diabetes, heart failure, chronic kidney disease)
- Cost and insurance coverage
- Dosing convenience
- Individual patient response to therapy 1
Practical Treatment Algorithm
Step 1: Initial Therapy
- Start with monotherapy using an ARB, ACE inhibitor, or calcium channel blocker 1
- Monitor blood pressure every 2-4 months once training begins 1
Step 2: If Blood Pressure Not Controlled
- Combine ARB with calcium channel blocker as the preferred two-drug combination 1, 9, 10
- Alternative: ARB with low-dose thiazide diuretic (though less ideal due to fluid/electrolyte concerns in athletes) 1
Step 3: If Triple Therapy Needed
- ARB + calcium channel blocker + low-dose thiazide diuretic (possibly with potassium-sparing agent) 1, 9
Critical Caveat:
Never combine an ARB with an ACE inhibitor—this dual RAS blockade increases cardiovascular and renal risk without additional benefit 1
Blood Pressure Targets for Athletes
- Stage 1 hypertension without target-organ damage: No restriction from competitive sports 1
- Target BP: <140/90 mmHg (or <130/80 mmHg per 2017 ACC/AHA guidelines for high-risk patients) 1
- Stage 2 hypertension (≥160/100 mmHg): Restrict from high static sports (weightlifting, wrestling, boxing) until controlled 1
Monitoring Requirements
When prescribing ARBs to athletes:
- Check renal function and potassium 1-2 weeks after initiation, with each dose increase, and at least yearly 1
- Assess for hypotension, particularly in volume-depleted athletes 1
- Screen for left ventricular hypertrophy with echocardiography if sustained hypertension present 1
What to Avoid in Athletes
- Beta-blockers: First-line in general population but impair exercise performance and are prohibited in certain sports 1, 3, 4
- Diuretics: Cause electrolyte disturbances and volume depletion problematic for athletes; also on doping lists for weight-class sports 1, 5
- Dual RAS blockade (ARB + ACE inhibitor): Increases harm without benefit 1