Perspective:

This study evaluated real-world outcome of patients with newly treated HTN initiating treatment with either an ACE inhibitor or ARB. The authors suggest the study supports starting ARBs over ACE inhibitors. However, no absolute risk values for any of the adverse effects are provided, and the issue of weight gain with ARBs compared to ACE inhibitors was not explored. The specific ACE inhibitors and ARBs used were not stated. Previous studies have reported a link between ACE inhibitors and pancreatitis. In ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), use of lisinopril was associated with increased risk of hospitalized gastrointestinal bleeding compared to both chlorthalidone and amlodipine (post-hoc analysis). Prior work from this group using the same database (LEGEND-HTN [Large-Scale Evidence Generation and Evaluation Across a Network of Databases for Hypertension]) found that diuretics had lower cardiovascular events than ACE inhibitors. Because generic medications in each class are readily available, neither ACE inhibitors nor ARBs have roadblocks associated with initiation selection. In practice, first-line treatments are initiated that are easiest for the clinician to manage and patient to take. Many patients require two or more drug regimens, but this was not addressed in the study. The focus remains getting people to goal and sustaining medication adherence.