COMMENTARY

ACEIs vs ARBs: What the Experts Use

Matthew F. Watto, MD; Paul N. Williams, MD

Disclosures

July 26, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Nelson Williams. Paul, how are things today?

Paul N. Williams, MD: I'm thrilled to hear once again that I'm a great friend, so I'm doing okay. How are you doing?

Watto: I'm doing well. Today we're going to be talking about some fantastic pearls on hypertension from the great Dr Jordana Cohen, who is a nephrologist and hypertension expert at the University of Pennsylvania.

Paul, to start us off, I wanted to remind you to beware of casual office blood pressure (BP), a term that I have come to love. This is when you enter the exam room and the patient is sitting on the exam table, talking on their phone, their arms and backs are not supported, and they haven't had any time to rest. You take a BP and it's 165/95. That is not the way BP is measured in research studies. When we state our BP target, which largely for most patients now is 130/80, certainly less than 140/90, it's based on how they measured BPs in research settings. The casual office measurement doesn't really meet up. Is everyone getting a casual BP? Or are they getting a perfect research study–quality BP?

Williams: No. Both in the office and, to be fair, probably at home too, if we're not careful, we're probably getting a more casual BP than a study-quality blood pressure. One point that Dr Cohen made is to make sure that you instruct patients how to take their BP properly at home as well.

Watto: Absolutely. And both the International Society for Hypertension guidelines — the KDIGO guidelines, the ACC/AHA guidelines — spend a lot of time just talking about how to measure BP. They have figures to share with patients as well. And the USPSTF guidelines recommend confirming the diagnosis of hypertension with home BP readings. So be sure that you're not just fooled by one reading in the office.

But Paul, are there other flavors of hypertension? Let's say the patient's BP is high at home and high in the office. I know what to do with that. That's sustained hypertension. But what other flavors exist? And what should people look out for?

Williams: Thank for teeing me up for my favorite hobbyhorse. Sustained hypertension is one flavor. The patient's BP is high both at home and in the exam room. Normotension or treated hypertension is when the patient's BP is normal both at home and in the office.

We are all at least aware of white coat hypertension, which is when the patient is hypertensive in the office but okay at home. In the past when I was just learning, we thought that was entirely benign. But it turns out to confer some cardiovascular risk. These are the patients in whom you might be more aggressive in treating. It's probably one of the few ways you can get insurance to pay for a 24-hour BP monitor, which is different from home BP monitoring.

The other flavor is masked hypertension, which is when the patient is normotensive in the office but hypertensive at home. Dr Cohen made the point that this is more common in men who use tobacco, and I've read in other papers that it's more common in patients who use alcohol or have some features of the metabolic syndrome as well. But in any case, it confers pretty significant cardiovascular risk, more so than almost any of the other flavors of hypertension. You're not going to see that unless you do home BP monitoring. This is another good argument, even for someone you think is probably doing okay but you have suspicion, that you should probably have them checking their BP at home.

Watto: Right. If they happen to have an EKG that shows LVH, or you find protein in their urine or they just seem generally unhealthy and you're surprised that they have normal BP, maybe that's somebody you check.

We have the patient's home BP readings, which were high quality. Now I want to start a medication. ACE inhibitors and ARBs [angiotensin-converting enzyme inhibitors and angiotensin receptor blockers]: Is there any difference between them? How do you think about them now, and has your practice changed recently?

Williams: I'm not sure how recently it has changed. A nice analysis by Chen and colleagues, from 2021, compared ACE inhibitors and ARBs. All the things that we liked about ACE inhibitors in terms of their renal protection or being helpful in systolic heart failure, ARBs do the same things. We know this, but it turns out that ARBs actually have a much more favorable side-effect profile. There is less cough and less angioedema. So in my own personal practice, I've been leading with the ARBs.

We talked with Dr Cohen about her favorite ARBs, and she has a similar practice. She doesn't start ACE inhibitors anymore. She favors the ARBs that have longer half-lives to mitigate the BP swings and to make patients' lives easier. Olmesartan is one of her personal favorites. We talked a little bit about losartan, which has a shorter half-life, so it is ideally dosed twice daily but is probably covered by most of the formularies. Valsartan is probably somewhere in the middle, with a nice longer half-life, but it is probably less potent. Telmisartan and candesartan also have nice longer half-lives, but I just don't see them used as often, and it might just be geographic variation.

Watto: Right. On some Twitter chat after the episode, she mentioned that olmesartan was just the example she happened to throw out, but there are other longer-acting ARBs. I hadn't really differentiated among the ARBs, so that was definitely practice-changing for me. Speaking of ARBs and ACE inhibitors, I had always been afraid to use them in patients with chronic kidney disease (CKD), but Dr Cohen said we should be prescribing them for these patients because there is cardiovascular benefit and renal protection. This was also practice-changing. I'm not sure about you. Are you more emboldened now to try them in patients with stable CKD?

Williams: For sure. She made the point that you can be comfortable with about a 30% increase in the creatinine level. She talked a little bit about the physiology behind that and how that actually showed that the medication was working.

Watto: The patients are hyperfiltering. When you add the drug, you're relaxing the outflow from the glomerulus so you get a little bit of decrease in hyperfiltration, which takes some of the pressure off the glomerulus. Naturally, you'd expect that if you're filtering less, you're going to have a little bit of a rise in creatinine. But that's okay, up to 30%. If it's beyond 30%, then you have to worry about whether the patient has bilateral renal artery stenosis. These medicines are better than hydrazine or beta-blockers for patients with CKD, and they are the meds I commonly see being prescribed when patients are afraid to use the ACE inhibitors and ARBs.

She also gave us an upper limit for potassium of 5.5 mmol/L for patients with CKD. They will typically have a slightly higher potassium level, so they tend to tolerate it. She said she will push the dose and continue it even if the potassium is up to 5.5 mmol/L. We talked more about CKD and diuretics. We can't go into all of the discussion on this short video, but spoiler alert: You can use diuretics in patients with CKD as well, even the thiazides.

So definitely check out the full episode of Hypertension FAQ: Common Outpatient Cases with Dr. Jordy Cohen, because there are so many great pearls.

Paul, should we sign off?

Williams: Now's the time. If you want to learn more, you know where to find us.

Watto: This has been another episode of The Curbsiders, bringing you a little knowledge food for your brain hole. Until next time, I'm Dr Matthew Frank Watto.

Williams: And I'm Dr Paul Williams. Thanks and goodbye.

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