Which ACE Inhibitor Is the Best for Hypertension?

Medically Reviewed on 11/30/2021
ace inhibitors for HBP
The best ACE inhibitors for hypertension include Trandolapril, Enalapril, and Ramipril.

Angiotensin-converting enzyme (ACE) inhibitors are a group of medications indicated for the treatment of hypertension (high blood pressure).

  • ACE inhibitors work by causing the kidneys to reduce the secretion of a substance called ACE, ultimately causing relaxation and widening of the blood vessel walls and reduction in blood pressure.
  • ACE inhibitors are prescribed as the first-line treatment of hypertension, especially in patients with heart disorders such as heart failure, both ST elevation, and non-ST elevation myocardial infarction, and in patients with chronic kidney disease with proteinuria (an abnormal condition in which high protein levels are seen in the urine).

Although ACE inhibitors are considered the first line of treatment for hypertension, they may be given in combination with other groups of antihypertensive agents such as diuretics, calcium channel blockers, angiotensin II receptor blockers, or direct renin inhibitors.

Random clinical trials done on participants show that no ACE inhibitor medicine appears to be better or worse than others in terms of blood pressure-reducing ability. However, several other studies conducted on ACE inhibitors reported that:

  • Trandolapril is more successful in lowering both systolic and diastolic blood pressure.
  • Enalapril effectively reduces blood pressure because it simultaneously improves heart function. However, it is associated with side effects such as increased cough, gastrointestinal discomfort, and impairment of kidney function in higher doses.
  • Ramipril was linked to the lowest risk of death from any cause.
  • Lisinopril was the least effective in blood pressure control and is associated with a high risk of death. However, it was effective in reducing albumin excretion in the urine in patients with diabetes.
  • The U.S. Food and Drug Administration approved captopril for diabetic nephropathy.

What are the examples of ACE inhibitors?

Drugs that come under the group angiotensin-converting enzyme (ACE) inhibitors include:

Except for captopril and lisinopril, all other drugs are prodrugs.

Prodrugs are drugs in their inactive form that have to be converted into their active forms in the body. This activation of prodrugs takes place in the liver. This implies that patients with liver anomalies are given active drugs such as captopril and lisinopril for the management of hypertension.

Some ACE inhibitors are metabolized by the liver and a few by the kidneys. Therefore, ACE inhibitors given may vary from patient to patient and are given according to their health conditions.

How do ACE inhibitors work?

As the name suggests, angiotensin-converting enzyme (ACE) inhibitors inhibit an enzyme named ACE and interfere with the renin-angiotensin–aldosterone system (RAAS), which plays a major role in maintaining blood pressure in the body.

  • ACE converts the hormone angiotensin I to its active form—angiotensin II—in the body. 
  • Hormone angiotensin II acts on the blood vessels and causes narrowing of the vessels (vasoconstriction).
  • Narrowing of the blood vessels caused by angiotensin II increases blood pressure. 
  • Moreover, angiotensin II stimulates the release of another hormone—aldosterone. 
  • Aldosterone is an antidiuretic hormone that increases the reabsorption of water and salt by the kidney. This increases in blood volume and eventually increases blood pressure.

ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, increasing the elimination of excess water and salt through the urine. With decreased blood volume, the cardiac output and stroke volume decrease, resistance in the renal blood vessels reduce, and venous capacity increases.

Bradykinin is another chemical that causes the blood vessels to widen (vasodilation). ACE participates in the breakdown of bradykinin. ACE inhibitors prevent the breakdown of bradykinin that resulting in high bradykinin levels, leading to dilation of the blood vessels.


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What are the uses of ACE inhibitors?

Apart from hypertension, angiotensin-converting enzyme inhibitors have been indicated to prevent, treat, or improve symptoms of various conditions, such as:

What are the side effects of ACE inhibitors?

Angiotensin converting enzyme (ACE) inhibitors are usually considered safe when taken in recommended doses. However, there are some side effects associated with them, which include:

A few serious side effects associated with ACE inhibitors may include:

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Medically Reviewed on 11/30/2021
Image Source: iStock Images

ACE inhibitors for the treatment of high blood pressure: https://www.cochrane.org/CD003823/HTN_ace-inhibitors-for-the-treatment-of-high-blood-pressure

Pharmacologic Management of Hypertension in Patients with Diabetes: https://www.aafp.org/afp/2008/1201/p1277.html

Comparison of the Efficacy and Safety of Different ACE Inhibitors in Patients With Chronic Heart Failure: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753869/#:~:text=CONCLUSION-,When%20considering%20factors%20such%20as%20increased%20ejection%20fraction%2C%20stroke%20volume,the%20most%20effective%20ACE%20inhibitor.