ACE Inhibitors vs. Beta Blockers

  • Medical Editor: John P. Cunha, DO, FACOEP
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

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ACE Inhibitors vs. Beta Blockers

  • ACE inhibitors (angiotensin converting enzyme inhibitors) and beta blockers are used to treat high blood pressure (hypertension) and congestive heart failure, to prevent kidney failure in patients with high blood pressure or diabetes, and to reduce the risk of stroke.
  • ACE inhibitors are also used to improve survival after heart attacks.
  • Beta-blockers are also used to treat abnormal heart rhythms, chest pain (angina), tremors, pheochromocytoma, hypertrophic subaortic stenosis, and to prevent migraines.
  • Examples of ACE Inhibitors include benazepril hydrochloride (Lotensin), captopril (Capoten), enalapril maleate (Vasotec), fosinopril sodium (monopril), lisinopril (Prinivel, Zestril), moexipril (Univasc), moexipril (Univasc), perindopril (Aceon), quinapril hydrochloride (Accupril), ramipril (Altace), and trandolapril (Mavik).
  • Examples of beta-blockers include acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), bisoprolol fumarate (Zebeta), carteolol hydrochloride (Cartrol), metoprolol tartrate (Lopressor), metoprolol succinate (Toprol-XL), nadolol (Corgard), penbutolol sulfate (Levatol), pindolol (Visken), propranolol hydrochloride (Inderal), solotol hydrochloride (Betapace), and timolol maleate (Blocadren).
  • Common side effects of ACE inhibitors include:
    • Cough
    • Skin rash
    • Changes in taste
  • Serious side effects of ACE inhibitors include:
    • Swelling (angioedema) of face, mouth, throat, airway
  • Common side effects of beta-blockers include:
    • Insomnia
    • Cold hands and feet
    • Tiredness or depression
    • Slow heartbeat
    • Symptoms of asthma
    • Impotence
  • Both ACE inhibitors and beta-blockers are not recommended for use during pregnancy. They may cause low blood pressure, excess potassium in the blood (hyperkalemia), kidney failure, and harm to a fetus.

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What are ACE Inhibitors and Beta-Blockers?

ACE inhibitors (angiotensin converting enzyme inhibitors) work by preventing a natural body substance called angiotensin I from converting into angiotensin II, which cases blood vessels to narrow and constrict. By preventing this change, the blood vessels remain relaxed and blood pressure decreases.

Beta-blockers, also known as beta-adrenergic blocking agents, block norepinephrine and epinephrine (adrenaline) from binding to beta receptors on nerves. This helps reduce the heart rate and lower blood pressure.

What are the side effects of ACE inhibitors and Beta blockers?

ACE Inhibitors

ACE inhibitors are well-tolerated by most individuals. Nevertheless, they are not free of side effects, and some patients should not use ACE inhibitors. ACE inhibitors usually are not prescribed for pregnant women because they may cause birth defects.

Individuals with bilateral renal artery stenosis (narrowing of the arteries that supply the kidneys) may experience worsening of kidney function, and people who have had a severe reaction to ACE inhibitors probably should avoid them.

The most common side effects are:

  • Cough
  • Elevated blood potassium levels
  • Low blood pressure,
  • Dizziness
  • Headache
  • Drowsiness
  • Weakness
  • Abnormal taste (metallic or salty taste)
  • Rash
  • Chest pain
  • Increased uric acid levels
  • Sun sensitivity
  • Increased BUN and creatinine levels

It may take up to a month for coughing to subside, and if one ACE inhibitor causes cough it is likely that the others will too. The most serious, but rare, side effects of ACE inhibitors are:

  • Kidney failure
  • Allergic reactions
  • Pancreatitis
  • Liver dysfunction
  • A decrease in white blood cells
  • Swelling of tissues (angioedema).

Beta blockers

Beta blockers may cause:

  • Diarrhea
  • Stomach cramps
  • Nausea
  • Vomiting

Other important side effects include:

  • Rash
  • Blurred vision
  • Disorientation
  • Insomnia
  • Hair loss
  • Weakness
  • Muscle cramps
  • Fatigue

As an extension of their beneficial effect, they slow heart rate and reduce blood pressure, but they may cause adverse effects such as heart failure or heart block in patients with heart problems.

Beta blockers should not be withdrawn suddenly because sudden withdrawal may worsen angina (chest pain) and cause heart attacks, serious abnormal heart rhythms, or sudden death.

  • Central nervous system effects of beta blockers include:
    • Headache
    • Depression
    • Confusion
    • Dizziness
    • Nightmares
    • Hallucinations

Beta blockers that block β2 receptors may cause shortness of breath in asthmatics. As with other drugs used for treating high blood pressure, sexual dysfunction may occur. Beta blockers may cause low or high blood glucose and mask the symptoms of low blood glucose (hypoglycemia) in people with diabetes.

Other serious side effects of beta-blockers include:

  • Toxic epidermal necrolysis
  • Raynaud's phenomenon
  • Lupus erythematosus
  • Bronchospasm
  • Serious allergic reactions
  • Erythema multiform
  • Steven Johnson Syndrome
  • Toxic epidermal necrolysis

What are the drugs that interact with ACE inhibitors and Beta blockers?

ACE Inhibitors

ACE inhibitors have few interactions with other drugs.

  • Since ACE inhibitors may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase the body's potassium may result in excessive blood potassium levels.
  • ACE inhibitors also may increase the blood concentration of lithium (Eskalith, Lithobid) and lead to an increase in side effects from lithium.
  • There have been reports that aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc.), indomethacin (Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the blood pressure lowering effects of ACE inhibitors.
  • Patients receiving diuretics may experience excessive reduction in blood pressure when ACE inhibitors are started. Stopping the diuretic or increasing salt intake prior to taking the ACE inhibitor may prevent excessive blood pressure reduction. Close supervision for at least two hours after the start of ACE inhibitors and until blood pressure is stable is recommended if the diuretic cannot be stopped.
  • ACE inhibitors should not be combined with ARBs because such combinations increase the risk of hypotension, hyperkalemia, and renal impairment.
  • ACE inhibitors should not be combined with aliskiren (Tekturna), another class of drugs that is used to treat high blood pressure because such combinations increase the risk of kidney failure, excessive low blood pressure, and hyperkalemia.
  • Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and low blood pressure) may occur when injectable (gold sodium aurothiomalate [Myochrysine]), used in the treatment of rheumatoid arthritis, is combined with ACE inhibitors.

Beta blockers

  • Combining propranolol (Inderal) or pindolol (Visken) with thioridazine (Mellaril) or chlorpromazine (Thorazine) may result in low blood pressure (hypotension) and abnormal heart rhythms because the drugs interfere with each other's elimination and result in increased levels of the drugs.
  • Dangerous elevations in blood pressure may occur when clonidine (Catapres) is combined with a beta blocker, or when clonidine or beta blocker is discontinued after their concurrent use. Blood pressure should be closely monitored after initiation or discontinuation of clonidine or a beta blocker when they have been used together.
  • Phenobarbital and similar agents may increase the breakdown and reduce blood levels of propanolol (Inderal) or metoprolol (Lopressor, Toprol XL). This may reduce effectiveness of the beta blocker.
  • Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) (for example, ibuprofen) may counteract the blood pressure reducing effects of beta blockers by reducing the effects of prostaglandins, which play a role in control of blood pressure.
  • Beta blockers may prolong hypoglycemia (low blood sugar) and mask symptoms of hypoglycemia in diabetics who are taking insulin or other diabetic medications.

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What are the different types of ACE inhibitors and Beta blockers?

ACE inhibitors

The following is a list of the ACE inhibitors that are available in the United States:

  • benazepril (Lotensin)
  • captopril (Capoten- discontinued brand)
  • enalapril (Vasotec, Epaned, [Lexxel- discontinued brand])
  • fosinopril (Monopril- Discontinued brand)
  • lisinopril (Prinivil, Zestril, Qbrelis)
  • moexipril (Univasc- Discontinued brand)
  • perindopril (Aceon)
  • quinapril (Accupril)
  • ramipril (Altace)
  • trandolapril (Mavik)

Beta blockers

The following is a list of the Beta blockers that are available in the United States:

  • acebutolol (Sectral)
  • atenolol (Tenormin)
  • betaxolol (Kerlone)
  • betaxolol (Betoptic S)
  • bisoprolol fumarate (Zebeta)
  • carteolol (Cartrol, discontinued)
  • carvedilol (Coreg)
  • esmolol (Brevibloc)
  • labetalol (Trandate [Normodyne - discontinued])
  • metoprolol (Lopressor, Toprol XL)
  • nadolol (Corgard)
  • nebivolol (Bystolic)
  • penbutolol (Levatol)
  • pindolol (Visken, discontinued)
  • propranolol (Hemangeol, Inderal LA, Inderal XL, InnoPran XL)
  • sotalol (Betapace, Sorine)
  • timolol (Blocadren, discontinued)
  • timolol ophthalmic solution (Timoptic, Betimol, Istalol)

REFERENCE: "Prevention and Treatment of High Blood Pressure: Types of Blood Pressure Medications"
American Heart Association

FDA Prescribing information

Summary

ACE inhibitors (angiotensin converting enzyme inhibitors) and beta-blockers are used to treat high blood pressure (hypertension) and congestive heart failure, to prevent kidney failure in patients with high blood pressure or diabetes, and to reduce the risk of stroke. Learn more about the side effects and drug interaction for these drug classes.

Treatment & Diagnosis

Medications & Supplements

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Reviewed on 10/5/2017
References
REFERENCE: "Prevention and Treatment of High Blood Pressure: Types of Blood Pressure Medications"
American Heart Association

FDA Prescribing information

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