For a typical adult who needs blood pressure control, heart‑failure benefit, or renal protection, which angiotensin‑II receptor blocker (ARB) is most preferred?

Preferred ARB Selection for Blood Pressure Control, Heart Failure, and Renal Protection

For heart failure patients intolerant to ACE inhibitors, candesartan and valsartan are the preferred ARBs based on proven mortality and hospitalization reduction, while for renal protection in diabetic nephropathy, losartan or irbesartan should be selected, and for general hypertension without compelling indications, any ARB provides equivalent blood pressure control. 1, 2, 3

Heart Failure: Candesartan and Valsartan Are Superior

Candesartan and valsartan have the strongest evidence for reducing hospitalizations and mortality in heart failure patients who cannot tolerate ACE inhibitors. 1, 2 The ACC/AHA guidelines specifically identify these two ARBs as having demonstrated benefit through reduced hospitalizations and mortality in heart failure trials. 1

• Candesartan dosing: Start at 4 mg once daily, titrate to target of 32 mg once daily 2
• Valsartan dosing: Start at 40 mg twice daily, titrate to target of 160 mg twice daily 2
• Losartan is notably absent from heart failure recommendations despite being widely used for other indications 1, 2

Critical Monitoring in Heart Failure

Check blood pressure, serum creatinine, and potassium within 1-2 weeks after initiating any ARB, with more frequent surveillance for patients with systolic BP <80 mmHg, low sodium, diabetes, or pre-existing renal dysfunction. 1, 2

Renal Protection: Losartan and Irbesartan for Diabetic Nephropathy

For diabetic patients with nephropathy requiring renal protection, losartan or irbesartan are the preferred ARBs based on specific trial data demonstrating renoprotective effects. 3, 4

• Both agents have demonstrated efficacy in slowing progression of diabetic kidney disease 3, 4
• For CKD stage 3 or higher with albuminuria ≥300 mg/day, ARBs are strongly recommended to slow kidney disease progression 1
• Telmisartan provides superior proteinuria reduction compared to losartan, even when blood pressures are equalized, likely due to higher receptor affinity and longer half-life 4

Renal Protection Dosing Strategy

• ACE inhibitors remain first-line for CKD with significant albuminuria; ARBs are reasonable alternatives if ACE inhibitors are not tolerated 1
• Do not initiate ARB therapy if serum potassium >5.0 mmol/L or creatinine >250 μmol/L until corrected 2
• Monitor renal function and potassium within 1-2 weeks of initiation and after each dose increase 1, 2

General Hypertension: All ARBs Are Equivalent

For uncomplicated hypertension without heart failure or significant renal disease, all ARBs provide equivalent blood pressure reduction and can be selected based on cost, dosing convenience, and tolerability. 1

• Losartan has specific evidence for reducing cardiovascular events by 13% and stroke by 25% in patients with left ventricular hypertrophy 3
• Standard ARB options include losartan 50-100 mg daily, telmisartan 40-80 mg daily, or olmesartan 20-40 mg daily 1, 2
• ARBs have significantly fewer adverse effects than ACE inhibitors, particularly regarding cough 3, 5

Critical Pitfalls to Avoid

Never combine ARBs with both ACE inhibitors and aldosterone antagonists—this dramatically increases risks of renal dysfunction and hyperkalemia without mortality benefit. 1, 2, 6

• Dual RAAS blockade (ARB + ACE inhibitor) is contraindicated due to increased renal dysfunction and hyperkalemia without improving cardiovascular outcomes 6, 7
• The addition of ARBs to adequate-dose ACE inhibitors provides no added benefit and increases adverse effects 1, 2
• Although angioedema is much less frequent with ARBs than ACE inhibitors, cases exist of patients developing angioedema to both drug classes 1

High-Risk Monitoring Populations

Patients with the following characteristics require particularly close surveillance during ARB therapy 1, 2:

• Systolic blood pressure <80 mmHg
• Low serum sodium
• Diabetes mellitus
• Impaired renal function (creatinine >1.6 mg/dL)
• Elderly patients or those with low muscle mass where creatinine underestimates renal dysfunction 1

Practical Dosing Algorithm

1. For heart failure (HFrEF or HFpEF): Use candesartan 4-32 mg daily or valsartan 80-320 mg daily (divided twice daily) 1, 2
2. For diabetic nephropathy with proteinuria: Use losartan 50-100 mg daily or irbesartan 1, 3, 4
3. For hypertension with left ventricular hypertrophy: Use losartan 50-100 mg daily 3
4. For uncomplicated hypertension: Any ARB is acceptable; select based on cost and dosing convenience 1

Target blood pressure <130/80 mmHg for all patients with hypertension and CVD, CKD, or 10-year ASCVD risk ≥10%. 1