What are the recommended first‑line ACE inhibitor and ARB medications for blood pressure control in patients with established heart disease?

Best ACE Inhibitors and ARBs for Heart Patients

For patients with established heart disease, ACE inhibitors or ARBs are first-line blood pressure medications, with beta-blockers added for compelling indications like recent MI or angina. 1

First-Line Medication Selection

ACE inhibitors and ARBs are equally effective for blood pressure control and cardiovascular outcomes in heart disease patients, but your choice should be guided by specific cardiac conditions 1:

For Coronary Artery Disease (CAD):

• Start with an ACE inhibitor or ARB as first-line therapy 1
• Add beta-blockers if the patient has recent MI or ongoing angina 1
• Target blood pressure <130/80 mm Hg 1
• Ramipril specifically reduced MI or stroke by 22% in CAD patients 1

For Heart Failure with Reduced Ejection Fraction (HFrEF):

• Sacubitril-valsartan (ARNI) is the preferred first choice over traditional ACE inhibitors or ARBs 1, 2
• If ARNI is not tolerated or available, use a traditional ACE inhibitor as second choice 2, 3
• ARBs (valsartan or candesartan) are reserved for ACE inhibitor-intolerant patients 1, 2
• Never combine an ACE inhibitor with an ARB—this combination is contraindicated 4, 2

For Post-Myocardial Infarction:

• Start an ACE inhibitor within 24 hours of STEMI in patients with heart failure, left ventricular dysfunction, or diabetes 3
• Captopril and valsartan showed equivalent efficacy in the VALIANT trial for high-risk post-MI patients 1
• Continue long-term for secondary prevention 1, 3

Specific Agent Recommendations

ACE Inhibitors (Preferred in Most Cases):

ACE inhibitors should be considered first choice over ARBs for reducing MI risk, primary prevention of heart failure, and secondary stroke prevention 3. Evidence favors:

• Ramipril for CAD patients (proven 22% reduction in MI/stroke) 1
• Captopril for post-MI patients with LV dysfunction 1
• Any ACE inhibitor at maximum tolerated dose for patients with albuminuria 1

ARBs (When ACE Inhibitors Not Tolerated):

• Valsartan for post-MI patients intolerant to ACE inhibitors 1
• Candesartan for heart failure when ACE inhibitors cause intolerable side effects 1
• ARBs have fewer adverse effects (particularly cough and angioedema) compared to ACE inhibitors, though outcomes are equivalent 5, 6

Combination Therapy Strategy

Most heart patients require multiple medications to achieve blood pressure targets 1:

1. Start with ACE inhibitor/ARB + beta-blocker for CAD with recent MI or angina 1
2. Add a dihydropyridine calcium channel blocker (like amlodipine) if blood pressure remains ≥130/80 mm Hg 1
3. Add a thiazide-like diuretic (chlorthalidone or indapamide preferred) as third agent if needed 1
4. Consider mineralocorticoid receptor antagonist for resistant hypertension on three drugs 1

Critical Pitfalls to Avoid

• Never combine ACE inhibitor + ARB—this increases adverse effects without additional benefit 1, 4, 2
• Do not use short-acting dihydropyridine calcium channel blockers (like immediate-release nifedipine) as they cause reflex sympathetic activation and worsen ischemia 1
• Monitor serum creatinine and potassium at least annually (or within 2-3 days after initiation) when using ACE inhibitors or ARBs 1, 2
• ACE inhibitor-related cough occurs commonly but can be reduced by switching to a lipophilic ACE inhibitor or adding a calcium channel blocker before abandoning the class entirely 3

Dosing Strategy

Titrate to maximum tolerated doses indicated for blood pressure treatment, not just symptom control 1:

• This approach maximizes cardiovascular and renal protection beyond blood pressure lowering 1
• For heart failure patients, uptitrate gradually while monitoring blood pressure, renal function, and potassium 2
• Target blood pressure <130/80 mm Hg in most heart patients, but avoid <120/70 mm Hg in heart failure 1