Which is Better for your Hypertensive: ACE-I or ARB?
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Which is Better for your Hypertensive: ACE-I or ARB?
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"Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin–angiotensin–aldosterone system inhibitors&nb
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Forums » Open clinical » Cardiology » Which is Better for your Hypertensive: ACE-I or ARB?
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Which is Better for your Hypertensive: ACE-I or ARB?
posted at 18/5/2012 1:44 PM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
"Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysisof randomized clinical trials of renin–angiotensin–aldosterone system inhibitors involving 158. 998 patients" European Heart Journal. Aims: Our objective was to analyse the effects of RAAS inhibitors as a class of drugs, as well as of angiotensin-converting enzyme (ACE) inhibitors and AT1 receptor blockers (ARBs) separately, on all-cause mortality. Results: The observed treatment effect resulted entirely from the class of ACE inhibitors, which were associated with a significant 10% reduction in all-cause mortality, whereas no mortality reduction could be demonstrated with ARB treatment. This difference in treatment effect between ACE inhibitors and ARBs on all-cause mortality was statistically significant. Conclusion: In patients with hypertension, treatment with an ACE inhibitor results in a significant further reduction in all-cause mortality. Because of the high prevalence of hypertension, the widespread use of ACE inhibitors may result in an important gain in lives saved. Comment: Again, the cheaper and generic medication looks better. Any other thoughts? All Best, Joey |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 18/5/2012 3:19 PM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Hi Joey I think earlier studies showed both having similar effects; now this one! Well let us see what opinion is adopted by academicians. I am concerned on two points. Price of ARB is much higher than that of ACE-I in Pakistan. But the marketing has almost eliminated the use of ACE-I in favour of ARB. That is deploreable. I condemn this approach. All patients first, should be prescribed ACE-I and only then if not tolerated, ARB should be tried. In Pakistan there is another problem. Quite higher percentage of patients, upto 30 % or even more, develop asthmatic cough with ACE-I. This may be due to environmental pollution, adding on the effects of ACE. But Surprising this is a statement in Current Medical Diagnosis and Treatment 2012,page 439. I quote; " " ARBs may synergize with ACE inhibitors in protection of heart and kidney, and ARB/ACE inhibitors combinations may also improve control of hypertension" Is this quote relevant? Would you also comment on combination of ACE/ARB. |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 18/5/2012 5:09 PM BST
on bmj.com
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Posts: 3045
First: 27/3/2012 Last: 20/5/2013 |
Of course the CEIs - the converting enzyme inhibitors should be the first choice for treatment of hypertensive patients, being safer & cost-effective. On the other hand ARBs, although effective & equally good in treating hypertension, the main limiting factors are the high cost & risk of serious side effects like anaphylaxis. |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 18/5/2012 9:06 PM BST
on bmj.com
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Posts: 579
First: 8/6/2011 Last: 22/5/2013 |
Hello to all of you and especialy to Ranasaleem ! I am happy to see you again on doc2doc. I would like to ad one more question for you all : I usually use ACE-I . But when i start a patient with this drug i have a little stess mostly because of the posibility of angioedema and and because the patients will buy it from the farmacy and usualy take it for first time when they are at home ( Many of them live more than 30 minutes of the nearest medical facility ) as you can understand if the patient will develop an angioedema will have not the time to be saved. Last years i heard that the possible complication of angioedema is happening mostly to older ACE-I' s and that the modern ones has not so many many possibilities. Are you aware of something like that ? And if yes which ACE-I you consider that are the safest in the matter of life dangerous sidereactions ? |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 19/5/2012 6:45 AM BST
on bmj.com
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Posts: 877
First: 17/6/2011 Last: 23/5/2013 |
I believe that ACE-I are better than ARB's and use them first line - as for angioedema I've seen one case in 15 years of prescribing them (and my interests are heart failure and imaging so I prescribe them a lot). Intractable cough is the main reason I change sadian |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 19/5/2012 10:30 AM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Hi ikaros Thank you for greeting. I am practicing for 30 years, and prescribing ACE for may be also 30 years. I have yet to see a case of Angioedema; So I am in agreement with sadian. Solution may be that you keep few doses in your clinic. You may give first dose in your clinic, provided you have the arrangements to manage the rare but feared complication. Any comment on the quote from CMDT 2012? |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 19/5/2012 11:14 PM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
Hello All and good to see you back to doc2doc Ranasaleem: When ARBs where introduced in the market they were advertised as more specific blockers (perhaps even more potent) of angiotensin II actions. No single Head to Head comparative studies between ACEIs and ARBs were ever done, and this premise is not true, threre are mechanisms of escape from angiotensin II blockade both with ACE-i and ARBs. Angioedema can happen with ACE-I, ARBs, and Aliskiren. Although much more common with ACE-Is than ARBs they are very much rare events, at least with these two agents (ACE-Is and ARBs). There is much more data in Hypertension and Heart Failure with ACE-Is than with ARBs. I also find that the data with ACE-Is more convincing than with ARBs both in Hypertension and Heart Failure. In Heart Failure I would say ACEIs are overwhelmingly superior than ARBs. And I also agree with Sadian that ACEIs are more potent than ARBs. I have about 10% of reluctant cough with ACEIs in my Hypertension clinic. When I start the treatment with ACE-Is I just tell my patients that the common cold (flu) will take a little longer to go away. The ONTARGET and the ALTITUDE studies have proved to me that we need some levels of angiotensin II in our bodies in states of health or disease for our proper functioning, in these both studies dual blockade was harmful to patients. So I never use the so-called dual-blockade of the renin-angiotensin system. I think the last NICE guidelines for Hypertension treatment are OK about this and about when to use ACE-Inhibitors. All Best, Joey
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 20/5/2012 12:22 PM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Hi Joey I am in complete agreement with you. Text books of this period of time are little hasty to add even flimsy opinions like double blockade. Some body should be writing to them, just in the interest of unwary readers. Everybody is not as well informed as Joey or sadian. Good to hear these things. |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 22/5/2012 3:28 PM BST
on bmj.com
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Posts: 43
First: 24/11/2010 Last: 1/10/2012 |
This was a very interesting discussion for me! Recently we saw a patient in the general surgical ward witha direct inguinal hernia which was preceded for 2 months by a dry cough which was later found to result from the use of ACEIs....A friend of mine added that his mother had developed the cough as well and another wondered aloud why ARBs weren't used first line.... Again, very interesting! |
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Re: Which is Better for your Hypertensive: ACE-I or ARB?
posted at 23/5/2012 8:35 AM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Dear Saqib sahib Thank God, the ACE-I were picked up as a reason for cough. This is usually missed. Many physicians, even experienced one and cardiologists, forget to tally the both things cough and ACE-I. ACE-I are being replaced as first line therapy in Pakistan; only due to aggresive marketing; at the additional cost of millions; Secondly ARBs are very mild anti-hypertensive as compared to ACE-I. The word must go out that ARB should be prescribed only if ACE-I are not tolerated. |
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