ACE Inhibitors vs. ARBs: How Do They Compare for High Blood Pressure?
Key takeaways:
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are both first-choice groups of medications for treating high blood pressure.
ACE inhibitors and ARBs have similar benefits, and both work equally well in the body.
ARBs seem to cause less side effects than ACE inhibitors. But some people and healthcare providers may be worried about using ARBs because of possible contamination issues with some of them.
If you’re being treated for high blood pressure, chances are you’re taking medication from one of two classes: Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). ACE inhibitors and ARBs are both first-choice options for treating high blood pressure.
But, you may be wondering what the difference is between them. Let’s take a look at how they compare.
What is hypertension?
Hypertension (high blood pressure) is when the pressure in your blood vessels is too high. High blood pressure often has no signs or symptoms, so many people don’t know whether their blood pressure is high until they’ve had it checked.
Chronic high blood pressure can be a big problem though. It raises the risk for health conditions like kidney disease, heart disease, and strokes. Luckily, there are several types of medication that treat high blood pressure. Two of the most common ones are ACE inhibitors and ARBs.
Which medications are ACE inhibitors and ARBs?
Below is a list of the medications included in each class. Most are available as lower-cost generics, and there are several medications to choose from in each class.
| ACE Inhibitors | ARBs |
|---|---|
| Lisinopril (Zestril) | Losartan (Cozaar) |
| Benazepril (Lotensin) | Irbesartan (Avapro) |
| Enalapril (Vasotec) | Olmesartan (Benicar) |
| Ramipril (Altace) | Valsartan (Diovan) |
| Quinapril (Accupril) | Telmisartan (Micardis) |
| Fosinopril | Candesartan (Atacand) |
| Captopril | Azilsartan (Edarbi) |
| Trandolapril | Moexipril |
| Perindopril |
How do they work?
ACE inhibitors and ARBs work on the same pathway in the body to control blood pressure, but at different spots.
ACE inhibitors block a natural substance (enzyme) in the body from converting angiotensin I into angiotensin II. Angiotensin II constricts the blood vessels, causing blood pressure to rise. Stopping this conversion relaxes blood vessels, which lowers blood pressure.
ARBs also target the angiotensin pathway. But they work by blocking angiotensin II from binding to receptors on the blood vessels. This also relaxes blood vessels and lowers blood pressure.
What are the similarities between the two medications?
Both ACE inhibitors and ARBs are usually taken once or twice a day. Both classes have several options, and most are available as lower-cost generics.
The American Academy of Family Physicians found that both classes of medication are similarly effective. They both lower blood pressure, reduce the risk of heart-related death, and lessen the risk of heart problems in people living with hypertension. A second review published in the Journal of Human Hypertension found similar results.
What are the differences between the two medications?
Although ACE inhibitors and ARBs are similar in many ways, there’s one main difference between them.
ACE inhibitors are more likely to have side effects. People are also more likely to stop taking them. The greater risk of side effects with ACE inhibitors may make ARBs a more attractive option for certain people.
But, certain ARBs were recalled in 2018, 2019, and 2020 because of possible contamination. This caused some people and healthcare providers to worry about their safety. Though it’s important to note that this only applied to specific lots of medication. The ARBs that are available now don’t have this risk.
What are their side effects?
The main disadvantage to using ACE inhibitors is that they can cause a dry hacking cough. Other side effects include:
Dizziness
Kidney problems
Low blood pressure
Very rarely, ACE inhibitors can cause angioedema. Angioedema is a medical emergency where the lips, tongue, and throat can swell up and interfere with breathing within minutes.
ARBs may also cause dizziness and low blood pressure. But they’re less likely to cause a cough. Angioedema is also less common with ARBs than with ACE inhibitors.
Which medications interact with ACE inhibitors and ARBs?
There are several medications that may interact with ACE inhibitors and/or ARBs. They include:
Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs — such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) — can prevent ACE inhibitors and ARBs from working as well. This combination may also raise the risk of kidney damage. Talk to your provider if you plan to take NSAIDs while you are taking an ACE inhibitor or ARB.
Medications that raise potassium levels: Salt substitutes and medications like spironolactone (Aldactone) may raise potassium levels. ACE inhibitors and ARBs also raise potassium. So if you take these medications together, your potassium level may go too high — which can be life threatening.
Lithium (Lithobid): Taking ACE inhibitors and ARBs with lithium may lead to higher levels of lithium in the blood and increase lithium’s side effects.
Other blood pressure medications: Taking an ARB or ACE inhibitor lowers your blood pressure. If you take another medication that does the same thing, your blood pressure could fall too low. This could make you dizzy or cause you to faint.
ACE inhibitors and ARBs should not be taken together. The combination may lead to dangerously low blood pressure, high blood potassium levels, and kidney problems.
Talk to your healthcare provider before making any changes to your medications. Be sure to bring along an up-to-date medication list for them to review.
Who should not take ACE inhibitors and ARBs?
Pregnant women should not take ACE inhibitors or ARBs. They can harm the unborn baby.
It may also be unsafe for people with severe kidney problems to take ACE inhibitors or ARBs. If your provider recommends that you take either of them, you and your provider will need to keep an eye on your kidneys. This will help prevent any harmful side effects.
You also should avoid ACE inhibitors or ARBs if you have a history of angioedema. Your healthcare provider can help you find out if this applies to you.
The bottom line
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are both first-choice medications for high blood pressure. They work on the same system in the body and work equally well in most people.
Also, ACE inhibitors may cause more side effects than ARBs. But the possibility of contamination in some ARBs has made some people hesitant to use them. Keep in mind that this only applies to specific batches of medication. The ARBs currently available don’t have this risk.
If you’re thinking about taking either medications, make sure you talk to your healthcare provider first.
Why trust our experts?
References
Dimou, C., et al. (2019). A systematic review and network meta-analysis of the comparative efficacy of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in hypertension. Journal of Human Hypertension.
Dreischulte, T., et al. (2015). Combined use of nonsteroidal anti-inflammatory drugs with diuretics and/or renin–angiotensin system inhibitors in the community increases the risk of acute kidney injury. Kidney International.
Gunasekaran, P. M., et al. (2019). Current status of angiotensin receptor blocker recalls. Hypertension.
Hill, R. D., et al. (2022). Angiotensin II receptor blockers (ARB). StatPearls.
Hollander-Rodriguez, J. C., et al. (2006). Hyperkalemia. American Family Physician.
Scully CBE, C. (2003). Drug effects on salivary glands: Dry mouth. Oral Diseases.
Turner, J. M., et al. (2020). Should angiotensin-converting enzyme inhibitors ever be used for the management of hypertension? Current Cardiology Reports.
Vega, I. L., et al. (2015). ACE inhibitors vs. ARBs for primary hypertension. American Family Physician.
Whelton, P. K., et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension.
