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Clinician’s Guide
T
his guide summarizes evidence comparing the
effectiveness and safety of angiotensin-
Clinical Bottom Line
converting enzyme inhibitors (ACEIs) and
Based on studies that compare an ACEI with an
angiotensin II receptor antagonists (ARBs) when
ARB, we know that:
used for adults with essential hypertension. The
evidence is derived from research studies comparing
I
ACEIs and ARBs work equally well to help adults
an ACEI with an ARB. with essential hypertension achieve blood
pressure control.
This guide does not review studies comparing
LEVEL OF CONFIDENCE
individual drugs within each class or evidence
about using ACEIs and ARBs for congestive heart I
Side effects are minimal. The main difference is
failure or diabetic kidney disease.
that ACEIs are more likely than ARBs to cause a
dry cough.
Clinical Issue
LEVEL OF CONFIDENCE
Both ACEIs and ARBs target the renin-
angiotensin-aldosterone system. As these drugs I
Both ACEIs and ARBs reduce proteinuria in
are equally effective for hypertension, the choice people who have hypertension. They do not differ
between ACEIs and ARBs will depend on the in the amount of proteinuria reduction. Neither
balance of side effects and cost. See the table on ACEIs nor ARBs change serum creatinine levels.
the reverse for typical doses and prices. LEVEL OF CONFIDENCE
Side Effects I
ACEIs and ARBs do not affect lipid levels or
Rates of side effects, such as headache and control of diabetes.
dizziness, are about the same for ACEIs and ARBs. LEVEL OF CONFIDENCE
The only significant difference is the rate of dry
cough. Cough occurs for 1–3 percent of people Confidence Scale
The confidence ratings in this guide are derived from a systematic review of
taking an ARB, and cough is about three times the literature. The level of confidence is based on the overall quantity and
more common for people taking an ACEI. On quality of clinical evidence.
average, discontinuation rates due to side effects High There are consistent results from good quality studies.
are 3 percent for people taking an ARB and Medium Findings are supported, but further research could
8 percent for those taking an ACEI. change the conclusions.
Low There are very few studies, or existing studies are flawed.
Serious Risks
Angioedema
Angioedema was so infrequently reported by Source
people taking ACEIs and ARBs that it is not The source material for this guide is a systematic review of
possible to estimate the actual risk. However, in 61 research studies in which an ACEI was compared with
the reviewed studies, it was reported only by people an ARB. The review, Comparative Effectiveness of Angiotensin-
taking ACEIs, about 1 in 10,000. Converting Enzyme Inhibitors (ACEIs) and Angiotensin II
Risk in Pregnancy Receptor Antagonists (ARBs) for Treating Essential Hypertension
When used during the second and third trimesters (2007), was prepared by the Duke Evidence-based Practice
of pregnancy, ACEIs and ARBs can cause injury Center. The Agency for Healthcare Research and Quality
and even death to the developing fetus. (AHRQ) funded the systematic review and this guide. The
guide was developed using feedback from clinicians who
reviewed preliminary drafts.
October 2007
ACEIS or ARBS for Adults With Hypertension: Clinician’s Guide