ACE inhibitors vs. ARBs: which is better?

Are ACE inhibitors or angiotensin receptor blockers better? The 2 minute update looks at a study evaluating mortality in patients started on both medicines.

We know that ACE inhibitors and angiotensin receptor blockers have a lot of benefits, but which should you pick? This is an observational study stemming from the UK and China. Total, it includes over 101,000 patients started on ACE inhibitors matched with the same number started on ARBs. About 1 in 6 were from the UK, with the remainder from China.

Mean age was around 63, with about 54% men and 46% women. Mean starting blood pressure was about 138/81 with mean estimated glomerular filtration rate about 84 mL/minute. The primary endpoint was all cause mortality.

The bottom line: there were fewer deaths with angiotensin receptor blockers. Five year all-cause mortality was 12 to 13% higher with ACE inhibitors, and the difference is statistically significant. There were also fewer cardiac events with ARBs than with ACE inhibitors.

Both ACE inhibitors and angiotensin receptor blockers are widely available as generic medications, and very affordable for the vast majority of patients. Personally, I stopped initiating patients on ACE inhibitors when the ARBs became available as generics, and I’ve never regretted that decision. I was taught in medical school that about 15% of people on ACE inhibitors develop that cough that will not quit, but I personally believe that everyone gets the cough, it just takes 15 or 20 years in some people.

There are still situations that demonstrate good evidence for ACE inhibitors over ARBs, particularly in certain high-risk cardiac and renal patients. So I would not get in a fight with your friendly cardiologist or nephrologist if they state they prefer ramipril or another ACE inhibitor for a particular patient. But for most patients, this study gives us good evidence that an ARB is a good choice. Personally, I prefer telmisartan due to its low cost and long half-life.

Reference: Xie et al. Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors Versus Angiotensin Receptor Blockers: Multidatabase Target Trial Emulation Studies. Hypertension 2025 September 4; Online ahead of print