1. Introduction

This guide summarizes evidence comparing the effectiveness and safety of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor antagonists (ARBs) when used for adults with essential hypertension. The evidence is derived from research studies comparing an ACEI to an ARB.

This guide does not review studies comparing individual drugs within each class or evidence about using ACEIs and ARBs for congestive heart failure or diabetic kidney disease.

Clinical Issue

Both ACEIs and ARBs target the renin-angiotensin-aldosterone system. As these drugs are equally effective for hypertension, the choice between ACEIs and ARBs will depend on the balance of side effects and cost. See the table in section 7 for typical doses and prices.

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2. Clinical Bottom Line

Confidence Scale

The confidence ratings in this guide are derived from a systematic review of the literature. The level of confidence is based on the overall quantity and quality of clinical evidence.

High

There are consistent results from good quality studies.

Medium

Findings are supported, but further research could change the conclusions.

Low

There are very few studies, or existing studies are flawed.

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3. Side Effects

Rates of side effects, such as headache and dizziness, are about same for ACEIs and ARBs. The only significant difference is the rate of dry cough. Cough occurs for 1 - 3 percent of people taking an ARB and cough is about three times more common for people taking an ACEI. On average, discontinuation rates due to side effects are 3 percent for people taking an ARB and 8 percent for those taking an ACEI.

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4. Serious Risks

Angioedema

Angioedema was so infrequently reported by people taking ACEIs and ARBs that it is not possible to estimate the actual risk. However, in the reviewed studies, it was reported only by people taking ACEIs, about 1 in 10,000.

Risk in Pregnancy

When used during the second and third trimesters of pregnancy, ACEIs and ARBs can cause injury and even death to the developing fetus.

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5. Resource for Patients

Comparing Two Kinds of Blood Pressure Pills: ACEIs and ARBs, A Guide for Adults is a companion to this Clinician’s Guide. It can help people talk with their health care professional about the effectiveness, side effects, and prices of ACEIs and ARBs.

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6. Still Unknown

Comparative studies have not yet determined if ACEIs and ARBs differ in:

• Rates of major cardiovascular events.
• Likelihood of developing diabetes.
• Effect on heart size and function.
• Effectiveness or tolerability for people taking other medications or with other medical problems.
• How well they work for men, women, people of different ages, or different ethnic groups.

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7. Price

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8. Source

The source material for this guide is a systematic review of 61 research studies in which an ACEI was compared with an ARB. The review, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Antagonists (ARBs) for Treating Essential Hypertension (2007), was prepared by the Duke Evidence-based Practice Center. The Agency for Healthcare Research and Quality (AHRQ) funded the systematic review and this guide. The guide was developed using feedback from clinicians who reviewed preliminary drafts.

AHRQ created the John M. Eisenberg Center at Oregon Health & Science University to make research useful for health care decisionmakers. This guide was prepared by Bruin Rugge, M.D., Theresa Bianco, Pharm.D., Sandra Robinson, M.S.PH., Valerie King, M.D., Martha Schechtel, R.N., and David Hickam, M.D., of the Eisenberg Center.

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9. For More Information

Visit the Consumer Guide Comparing Two Kinds of Blood Pressure Pills: ACEIs and ARBs.

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