By Amy Norton
HealthDay reporter
TUESDAY, July 27, 2021 (HealthDay News) – Two long-used types of blood pressure medication are equally effective, but the less popular one appears to have fewer side effects, according to a large “real world” study.
The two drug classes are both recommended as first-line treatments for high blood pressure: angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB).
ACE inhibitors have been around for a while and they have been studied more intensely, so doctors are more likely to prescribe them.
However, the new results suggest that ARBs might be a better choice for people just starting out on medication, the researchers said.
“There was no difference in the effectiveness of the drugs,” said lead researcher Dr. George Hripcsak. “If you don’t have any side effects [with an ACE inhibitor]there is no need to switch. “
Using data from nearly 3 million patients, the researchers found that ACE inhibitors and ARBs were equally effective in lowering the risk of heart disease and stroke.
What made them different were side effects: ACE inhibitors were more likely to cause chronic cough and angioedema – severe swelling under the skin, often on the face.
People who received ACE inhibitors were also slightly more likely to have gastrointestinal (GI) bleeding or inflammation of the pancreas. But those differences could be down to chance, warned Hripcsak, a professor at Columbia University’s Vagelos College of Physicians and Surgeons in New York City.
In the future, he said, doctors might “preferentially” prescribe ARBs as the first treatment for high blood pressure. This class of drugs includes losartan, valsartan, and candesartan.
But people who are already using an ACE inhibitor and are doing well can stick with it. ACE inhibitors include lisinopril, captopril, and fosinopril.
The study was published online in the journal Hypertension on July 26th.
There is a long list of drugs for high blood pressure, and guidelines recommend both ACE inhibitors and ARBs as first-line options. Both classes have been shown to be effective in lowering blood pressure and reducing the risk of heart disease and stroke.
But, Hripcsak said, few studies have done head-to-head comparisons of the two types of drugs to help doctors make decisions.
So his team looked for real data. They used several large databases from the US, South Korea and Europe with health records of nearly 3 million patients who started new on an ACE inhibitor or an ARB between 1996 and 2018.
The vast majority – nearly 2.3 million – were prescribed an ACE inhibitor as the only blood pressure medication. The rest (nearly 674,000) were launched on an ARB.
Overall, the study found no clear difference between the two groups in terms of their average risk of having a heart attack, stroke, or heart failure.
However, ACE inhibitor patients were three times more likely to develop angioedema and 32% more likely to develop a persistent cough, the results showed.
The risk of gastrointestinal bleeding and pancreatitis was also slightly higher in ACE inhibitor users. However, these numbers did not stand up to a statistical analysis conducted by the researchers, which means that they could be random results.
Dr. Willie Lawrence is a cardiologist at the Center for Better Health in Benton Harbor, Michigan. He said that in his experience, gastrointestinal bleeding and pancreatitis were not problems with the drugs.
On the other hand, angioedema and “ACE cough” are known potential side effects, said Lawrence, who chairs the oversight committee of the American Heart Association’s National Hypertension Control Initiative.
There was already a feeling that ARBs were less likely to cause these problems, Lawrence said. But since ACE inhibitors have been around for a long time, doctors have tended to prescribe them more often, he added.
“I think this study begs the question of whether it is better to go straight to an ARB,” said Lawrence.
The study doesn’t provide a solid answer, however: observational studies like this one, tracking patients with a given treatment in the real world, have inherent limitations. Controlled clinical trials that aim to test a treatment in a targeted manner offer better evidence.
However, it’s unlikely anyone will do a study of ACE inhibitors against ARBs, Lawrence said. Both drug classes are already widespread and available as inexpensive generics, so there is no incentive for drug manufacturers to conduct expensive studies.
“I think patients should be aware that ACE inhibitors can cause cough and angioedema, and if you develop these symptoms, tell your GP,” said Lawrence.
But like Hripcsak, he said that patients who are fine with an ACE inhibitor have no reason to change anything.
More information
The American Heart Association has advice on treating high blood pressure.
SOURCES: George Hripcsak, MD, Professor and Chair of Biomedical Computer Science, Columbia University Vagelos College of Physicians and Surgeons, New York City; Willie Lawrence, MD, director, National Hypertension Control Initiative Oversight Committee, American Heart Association, Dallas, and interventional cardiologist, Center for Better Health, Benton Harbor, Michigan; Hypertension, July 26, 2021, online
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