How much will an angiotensin-converting enzyme (ACE) inhibitor lower my blood pressure?

Evidence shows that lowering blood pressure (BP) decreases the risk of adverse cardiovascular outcomes such as heart disease, stroke, and death.^1-5 It may also slow the progression of kidney damage in people with chronic kidney disease (CKD).⁶ Further, meta-analyses as well as national and international guidelines suggest that lowering BP decreases risk of these outcomes regardless of which agent is used.^1-5,7

Angiotensin-converting enzyme (ACE) inhibitors are a first-line treatment for all stages of hypertension as a monotherapy or in combination with one or more other antihypertensive agents.^1-5,8 Studies have found no significant efficacy differences between the individual ACE inhibitors.^8,9

Monotherapy trials show the BP lowering efficacy of ACE inhibitors.^10-15 A 2008 Cochrane Review meta-analysis found 92 randomized controlled trials (RCTs) that studied the dose-related trough BP lowering efficacy of 14 ACEIs in 12,954 participants.⁸ The baseline BP was 157/101 mm Hg across the trials. ACE inhibitors lowered BP measured one to 12 hours after the dose by about 11/6 mm Hg. The best estimate or trough BP lowering effect for ACEIs based on the largest trials was -8 mm Hg for systolic blood pressure and -5 mm Hg for diastolic blood pressure. The analysis also found that a dose of 50% of the maximum (max) daily dose had a BP lowering effect that was 90% of max and that ACE inhibitor doses above the max dose did not lower BP significantly any more than the max dose.

A 2015 meta-analysis of five major antihypertensive drug classes found 12 RCTs and 13 randomized comparisons (35,707 patients) in which an ACE inhibitor was the active treatment drug.¹⁶ The review found that an systolic BP/diastolic BP difference of about -4/-2 mm Hg between ACE inhibitor therapy versus placebo was associated with significant reductions in the relative risk of all outcomes, except cardiovascular and all-cause mortalities. The analysis found that stroke was reduced by –20% (–7 to –31%), heart failure by –21% (–7 to –34%), coronary heart disease (CHD) by –13% (–3 to –21%) and major cardiovascular events (composite of stroke, CHD and heart failure) by –17% (–8 to 25%). Cardiovascular mortality (11% reduction) and all-cause mortality (8% reduction) did not achieve statistical significance.

A 2011 Cochrane Review meta-analysis found four RCTs (three comparing ACE inhibitors to placebo and one comparing ACE inhibitors with angiotensin receptor blockers [ARBs]) with a total 2,177 participants that reported the effect of ACE inhibitors on people with early (stage 1 to 3) CKD who do not have diabetes mellitus.¹⁷ The review concluded that there is insufficient evidence showing the effectiveness of ACE inhibitors in preventing all-cause mortality or cardiovascular events in people with CKD who do not have diabetes.

However, the 2012 KDIGO clinical practice guideline recommends an ACE inhibitor or ARB be used in diabetic adults with CKD and urine albumin excretion 30 to 300 mg/24 hours.⁶ The guideline also recommends that an ARB or ACE inhibitor be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours.

^References

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