All in on ARBs: Is it time to fold the ACEIs?

OBJECTIVE

To summarize the efficacy and safety of angiotensin II receptor blockers (ARBs) compared to angiotensin-converting enzyme inhibitors (ACEIs) in primary hypertension and other compelling indications, focusing on cardiovascular and renal outcomes.

QUALITY OF EVIDENCE: Relevant randomized controlled trials and systematic reviews were identified through the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. Additional clinical evidence was manually retrieved from the PubMed database.

MAIN MESSAGE: Inhibitors of the renin-angiotensin-aldosterone system are cornerstone therapies in the management of primary hypertension with or without comorbidities. ACEIs have traditionally been preferred by many clinicians due to their long-standing use, robust efficacy, and low cost. However, current evidence supports comparable efficacy between ARBs and ACEIs in managing primary hypertension, cardiovascular disease, heart failure, chronic kidney disease, and diabetes. Importantly, ARBs consistently demonstrate a more favourable safety profile in head-to-head trials, particularly in reducing cough and angioedema. With most agents now available as generics, ARBs are also cost comparable. That said, in patients with stage 3 to 5 chronic kidney disease, limited evidence suggests that ACEIs may confer superior renoprotective benefits. In 2022, approximately 11.3% of Canadians were prescribed an ACEI, compared with only 7.7% prescribed an ARB. These findings suggest a disconnect between current prescribing patterns and current evidence, warranting reconsideration of ARBs as a preferred first-line option in many patients.

CONCLUSION

While ARBs and ACEIs demonstrate comparable cardiovascular and renal efficacy across hypertension and other compelling indications, ARBs show a substantially better safety profile in head-to-head comparisons, supporting their broader use in clinical practice.