What is the best angiotensin receptor blocker (ARB) for hypertension?

Best ARB for Hypertension

There is no single "best" ARB—guidelines consistently recommend ACE inhibitors or ARBs as a class without distinguishing between individual agents, as all ARBs provide equivalent cardiovascular protection when used at appropriate doses. 1

Guideline-Based Approach to ARB Selection

Primary Recommendation Framework

• Guidelines treat all ARBs as therapeutically equivalent for hypertension management, recommending "an ACE inhibitor or ARB" without specifying individual agents 1
• The 2024 ESC Guidelines and 2015 ADA Standards both recommend ARBs as a class for blood pressure control, with selection based on patient-specific factors rather than superiority of one agent 1
• ARBs should only be used when ACE inhibitors are not tolerated (typically due to cough), as ACE inhibitors have more robust cardiovascular outcome data in most populations 1, 2

When ARB Selection Matters: Evidence-Based Distinctions

While guidelines don't differentiate between ARBs, the highest quality recent evidence suggests:

• Olmesartan and telmisartan demonstrate superior blood pressure reduction compared to other ARBs in head-to-head trials, with olmesartan ranking highest for office BP reduction (91.4% for systolic, 87.2% for diastolic) and telmisartan for 24-hour ambulatory BP control 3
• Telmisartan has the strongest cardiovascular outcome data among ARBs, showing equivalent protection to ramipril (an ACE inhibitor) in the ONTARGET trial with better tolerability 4
• Azilsartan (80 mg) showed superior systolic BP reduction compared to valsartan 320 mg or olmesartan 40 mg in short-term studies, though cardiovascular outcome data are lacking 5

Practical Selection Algorithm

For uncomplicated hypertension:

• Start with any ARB at appropriate doses (losartan 50-100 mg, valsartan 80-320 mg, irbesartan 150-300 mg, candesartan 4-16 mg, telmisartan 40-80 mg) 1
• If maximal BP reduction is the priority, consider olmesartan or telmisartan based on 2024 network meta-analysis 3

For high cardiovascular risk patients (diabetes, CAD, prior MI):

• Prefer ACE inhibitors over ARBs as first-line unless contraindicated 2
• If ARB required due to ACE inhibitor intolerance, telmisartan has the strongest cardiovascular outcome evidence 4
• Titrate to maximum tolerated dose indicated for BP treatment, not just to BP targets 2

For heart failure:

• Candesartan, valsartan, and losartan have proven mortality benefits in heart failure trials 1
• ARBs are appropriate only if ACE inhibitors are not tolerated 1

Critical Monitoring and Combination Therapy

• Monitor serum creatinine, eGFR, and potassium at baseline and regularly during ARB therapy 1, 6
• Most patients require multiple agents to reach BP goal <130/80 mmHg 2
• Combine ARBs with thiazide-like diuretics or dihydropyridine calcium channel blockers, not with other RAS blockers 1, 2
• Never combine ARB + ACE inhibitor, ARB + direct renin inhibitor, or ARB + another ARB—this increases hyperkalemia and acute kidney injury risk without benefit 2

Common Pitfalls to Avoid

• Do not assume all ARBs are identical in potency—dosing equivalence varies significantly (candesartan 4-16 mg vs. valsartan 80-320 mg) 1
• Valsartan and losartan consistently rank lower in BP reduction efficacy compared to newer ARBs 3
• ARBs are contraindicated in pregnancy, bilateral renal artery stenosis, and history of angioedema 2
• When adding a fourth agent for resistant hypertension, use spironolactone (if K+ <4.5 and eGFR >45), not an additional ARB 6