Practice Therapeutics

Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in hypertension

BMJ 2011; 342 doi: (Published 07 April 2011) Cite this as: BMJ 2011;342:d1673
  1. J M Ritter, emeritus professor of clinical pharmacology, King’s College London
  1. 1Department of Clinical Pharmacology, St Thomas’ Hospital, London SE1 7EH, UK
  1. james.ritter{at}
  • Accepted 4 February 2011

Case scenario

A 45 year old white man is noted incidentally to have a raised systolic blood pressure of 160 mm Hg when he presents with a minor respiratory tract infection. It remains raised at follow-up visits, despite his efforts at non-drug treatment (including dietary salt restriction). He has electrocardiographic evidence of left ventricular hypertrophy by voltage criteria but does not have diabetes or dyslipidaemia. His estimated 10 year cardiovascular risk (stroke and myocardial infarction combined) is 26%. Routine investigations do not raise suspicion of an underlying cause of hypertension.

First line antihypertensive drugs are classified as A, B, C, or D.1 Drugs classed as A comprise angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs); B drugs are β adrenoceptor antagonists (also known as β blockers) and have fallen out of favour for use as single agents in patients in whom uncomplicated essential hypertension is the sole indication for drug treatment; C drugs are calcium antagonists; and D drugs are diuretics. This mnemonic can usefully guide initial treatment (see box 1) as well as addition of a second agent when needed2 and is used in the National Institute for Health and Clinical Excellence (NICE) guideline on management of hypertension in adults in primary care.3 Randomised controlled trial data show that untreated patients with essential hypertension with normal or raised plasma renin concentration (for example, many younger patients with essential hypertension, especially those who have successfully reduced their dietary salt intake) respond rather better to A and B drugs, whereas those with low renin (such as people of African origin and older patients) respond well to C or D drugs).1 The table summarises the advantages and disadvantages of the main classes of drugs used to start treatment of hypertension.

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Advantages and disadvantages of the main classes …

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