TUESDAY, July 27, 2021 (HealthDay News) -- Two long used types of blood pressure drugs are equally effective, but the less popular one seems to have fewer side effects, according to a large "real-world" study. The two classes of medication are both recommended as "first-line" treatments for high blood pressure: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). ACE inhibitors have been around longer and studied more extensively, so doctors prescribe them more often. But the new findings suggest that ARBs might be a better choice for people just starting on medication, the researchers said. "There was no difference in the effectiveness of the drugs," senior researcher Dr. George Hripcsak said. "If you're not having side effects [with an ACE inhibitor], there's no need to switch." Looking at data on nearly 3 million patients, the investigators found that ACE inhibitors and ARBs were equally effective at lowering the risks of heart disease and stroke. Where they differed was side effects: ACE inhibitors were more likely to cause chronic cough and angioedema — severe swelling under the skin, often in the face. People on ACE inhibitors were also slightly more likely to have gastrointestinal (GI) bleeding or inflammation of the pancreas. But those differences may have been due to chance, cautioned Hripcsak, a professor at Columbia University Vagelos College of Physicians and Surgeons, in New York City. Going forward, he said, doctors might want to "preferentially" prescribe ARBs as a first treatment for high blood pressure. This class of drugs includes Losartan, Valsartan and Candesartan. But people who are already using an ACE inhibitor and doing fine can stick with it. ACE inhibitors include lisinopril, captopril and fosinopril. The study was published online July 26 in the journal Hypertension. There is a long list of medications for high blood pressure, and guidelines recommend both ACE inhibitors and ARBs as first-line options. Both classes have been proven effective in lowering blood pressure and curbing the risks of heart disease and stroke. But, Hripcsak said, few trials have made head-to-head comparisons of the two drug types to help doctors make decisions on which to prescribe. So his team looked to real-world data. They used a few large databases from the United States, South Korea and Europe, with health records from nearly 3 million patients who were newly starting an ACE inhibitor or an ARB sometime between 1996 and 2018. The large majority — almost 2.3 million — were prescribed an ACE inhibitor as their single blood pressure medication. The rest (almost 674,000) were started on an ARB. Overall, the study found, there was no clear difference between the two groups in their average risk of suffering a heart attack, stroke or heart failure. ACE inhibitor patients were, however, three times more likely to develop angioedema, and 32% more likely to develop a persistent cough, the findings showed. The risks of GI bleeding and pancreatitis were also slightly higher among ACE inhibitor users. But those figures did not hold up to a statistical analysis the researchers performed, which means they could be chance findings. Dr. Willie Lawrence is a cardiologist at the Center for Better Health, in Benton Harbor, Mich. He said that, in his experience, GI bleeding and pancreatitis have not been issues with the medications. On the other hand, angioedema and "ACE cough" are well-known potential side effects, said Lawrence, who heads the American Heart Association's National Hypertension Control Initiative Oversight Committee. There has already been a sense that ARBs are less likely to cause those problems, Lawrence said. But since ACE inhibitors have been available longer, doctors are inclined to prescribe them more often, he added. "I think this study raises the question of whether it's better to just go straight to an ARB," Lawrence said. But, he noted, the study does not provide a solid answer: There are inherent limits to observational studies such as this, which track patients given a particular treatment in the real world. Controlled clinical trials, which are designed to specifically test a treatment, offer better evidence. However, it's unlikely anyone will conduct a trial pitting ACE inhibitors against ARBs, Lawrence said. Both drug classes are already widely used and available as inexpensive generics, so there's no incentive for drug makers to run expensive trials. "I think patients should be aware that ACE inhibitors can cause cough and angioedema, and if you develop those symptoms, tell your primary care provider," Lawrence said. But, like Hripcsak, he said that patients who are faring well with an ACE inhibitor have no reason to make a change. More information The American Heart Association has advice on managing high blood pressure. SOURCES: George Hripcsak, MD, professor and chair, biomedical informatics, Columbia University Vagelos College of Physicians and Surgeons, New York City; Willie Lawrence, MD, head, National Hypertension Control Initiative Oversight Committee, American Heart Association, Dallas, and interventional cardiologist, Center for Better Health, Benton Harbor, Mich.; Hypertension, July 26, 2021, online High blood pressure can lead to many serious health problems, such as heart attack, heart failure, stroke, and kidney disease. Treating high blood pressure early is important in preventing these and other problems. Dozens of different medications can help treat high blood pressure. These drugs are called antihypertensives. They’re divided into many different categories, each of which works differently and causes different side effects. With so many options available, finding the best one for you may take some time and patience. Your doctor will work with you to find the best treatment plan for you, which may include one or more medications. Diuretics are some of the most commonly used drugs for treating high blood pressure. They help the kidneys get rid of excess water and sodium, or salt. This reduces the volume of blood that needs to pass through your blood vessels, which lowers your blood pressure. There are three major types of diuretics: thiazide, potassium-sparing, and loop diuretics. Thiazide diuretics generally have fewer side effects than the others. This is especially true when they’re prescribed in the low doses that are generally used in treating early high blood pressure. Examples of thiazide diuretics include:
Examples of potassium-sparing diuretics include:
Examples of loop diuretics include:
Examples of combination diuretics include:
Beta-blockers work by blocking the actions of chemicals in your body that stimulate your heart. This allows your heart to beat with less speed and force. Your heart pumps less blood through the blood vessels with each beat, so blood pressure decreases. Examples of these drugs include:
ACE inhibitors keep the body from making a hormone called angiotensin II, which causes blood vessels to narrow. These medications lower blood pressure by helping constricted blood vessels expand to let more blood through. Examples of ACE inhibitors include:
On April 22, 2022, Pfizer issued a voluntary recall of 5 lots of the drug Accupril due to the presence of nitrosamine. Nitrosamine, a known carcinogen with the potential to cause cancer, was found to exist in the drug at levels greater than the Acceptable Daily Intake (ADI) as determined by the FDA. This recall is specific only to a handful of lot numbers and does not affect all Accupril tablets made by Pfizer. If you take Accupril tablets, talk with your pharmacist or doctor and they will help you determine if your medication has been impacted by the recall. This class of drugs also protects the blood vessels from angiotensin II. In order to tighten blood vessels, angiotensin II must bind with a receptor site. ARBs prevent that from happening. As a result, blood pressure is lowered. Examples of ARBs include:
To move, all muscles need calcium to flow in and out of the muscle cells. Calcium channel blockers help block calcium from entering the smooth muscle cells of the heart and blood vessels. This makes the heart beat with less force and helps blood vessels relax. As a result, blood pressure decreases. Examples of these drugs include:
In certain situations, your body makes hormones called catecholamines. These hormones can bind to parts of cells called alpha-receptors. When this occurs, your blood vessels narrow and your heart beats faster and with more force. These actions cause your blood pressure to rise. Alpha-blockers work by blocking catecholamines from binding to alpha-receptors. As a result, blood can flow through the blood vessels more freely, and your heart beats normally. This helps lower your blood pressure. Examples of alpha-blockers include:
Alpha-beta-blockers have a combined effect. They block the binding of catecholamine hormones to both alpha- and beta-receptors. Therefore, they can decrease the constriction of blood vessels like alpha-blockers do. They also slow down the rate and force of the heartbeat like beta-blockers do. Examples of alpha-beta-blockers include:
These medications keep the brain from sending messages to the nervous system telling it to release catecholamines. As a result, the heart doesn’t pump as hard and blood flows more easily, lowering blood pressure. Examples of central agonists include:
Vasodilators relax the muscles in the walls of blood vessels, especially in small arteries called arterioles. This widens the blood vessels and allows blood to flow through them more easily. As a result, blood pressure falls. Examples of vasodilators include:
Aldosterone receptor antagonists work by blocking a chemical called aldosterone. This action reduces the amount of fluids your body retains, which helps lower your blood pressure. Examples of aldosterone receptor antagonists include:
A newer type of blood pressure medication is called direct renin inhibitors (DRIs). These drugs block a chemical in your body called renin. This action helps widen your blood vessels, which lowers your blood pressure. The only type of DRI that is currently available in the United States is: For most people, the first-choice medication for high blood pressure is a thiazide diuretic. For other people, a diuretic alone is not enough to control blood pressure. In these cases, a diuretic may be combined with a beta-blocker, ACE inhibitor, angiotensin II receptor blocker, or calcium channel blocker. Adding a second medication may lower your blood pressure more quickly than using a diuretic alone. Also, it allows you to take less of each medication, which may reduce side effects. Combination drugsIf your doctor thinks you need more than one drug to manage your blood pressure, they may prescribe a combination medication. For instance, they may prescribe a beta-blocker with a diuretic, or an ARB with a calcium channel blocker. Using these combination medications may be more convenient than taking several different drugs each day. Many combination medications to treat high blood pressure are available. Examples include:
Treating for multiple conditionsThe type of blood pressure medication your doctor prescribes may depend on what other health problems you have. For example, if you have coronary artery disease (CAD) and high blood pressure, your doctor may prescribe a beta-blocker. If you have had a myocardial infarction due to CAD, a beta-blocker can lower your blood pressure and decrease your overall risk of death. If you have diabetes, your doctor may choose an ACE inhibitor or an ARB. That’s because these drugs can help protect the kidneys from diabetic damage by lowering the blood pressure in your kidneys. High blood pressure is a serious condition that requires treatment to prevent more severe health problems. Don’t worry if you’re confused by all of your medication options. Your doctor can tell you which drugs might work best for you. Together, you can put together a treatment plan to get your blood pressure under control. Some questions to ask your doctor include:
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