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All in on ARBs: Is it time to fold the ACEIs?
Philippe Phan1, Benjamin Pham2, Melanie Yang3
1Pharmacist at Jean Coutu in Granby, Que, an independent clinical analyst contracted with Vigilance Santé, and a graduate diploma in clinical epidemiology candidate at McMaster University in Hamilton, Ont.
Canadian Family Physician Medecin De Famille Canadien
|March 17, 2026
Summary
Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) offer similar benefits for cardiovascular and kidney health in hypertension. ARBs present a superior safety profile, making them a strong alternative first-line treatment.
Area of Science:
- Cardiovascular Medicine
- Nephrology
- Pharmacology
Background:
- Renin-angiotensin-aldosterone system inhibitors are crucial for managing hypertension.
- Angiotensin-converting enzyme inhibitors (ACEIs) have been historically preferred due to established efficacy and cost.
- Emerging evidence necessitates a re-evaluation of treatment guidelines.
Purpose of the Study:
- To compare the efficacy and safety of ARBs versus ACEIs.
- To analyze cardiovascular and renal outcomes in primary hypertension and other conditions.
- To inform clinical practice regarding first-line antihypertensive therapy.
Main Methods:
- Systematic review of randomized controlled trials and systematic reviews.
- Searches conducted in MEDLINE, Embase, Cochrane Central, and PubMed.
- Analysis focused on cardiovascular, renal, and safety outcomes.
Main Results:
- ARBs and ACEIs demonstrate comparable efficacy in hypertension, cardiovascular disease, heart failure, chronic kidney disease, and diabetes.
- ARBs exhibit a significantly better safety profile, with less cough and angioedema.
- Limited data suggests ACEIs may offer superior renoprotection in advanced chronic kidney disease (stages 3-5).
- Current prescribing patterns in Canada show higher ACEI use than ARB use, despite comparable efficacy and ARB safety advantages.
Conclusions:
- ARBs and ACEIs provide similar cardiovascular and renal benefits.
- ARBs possess a superior safety profile, supporting their wider adoption.
- Reconsideration of ARBs as a preferred first-line agent is warranted for many patients.
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