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Evidence summaries

Blood Pressure Lowering Efficacy of Angiotensin Receptor Blockers for Primary Hypertension

Blood pressure (BP) lowering effect of angiotensin receptor blockers (ARBs) as a class appears to be modest (-8/-5 mm Hg) and 60 to 70% of this trough BP lowering effect occurs with recommended starting doses. There may not be clinically meaningful BP lowering differences between available ARBs. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 46 studies with a total of 13 451 subjects (mean age 55 years and baseline BP 156/101 mm Hg) evaluating the dose-related trough BP lowering efficacy of 9 ARBs. The best estimate of the blood pressure lowering efficacy of these 9 drugs ranged from -6/-3 mm Hg to -10/-7 mm Hg. The data did not suggest that any one ARB is better or worse than any other at lowering blood pressure when used at maximal recommended doses. A dose of 1/8 or 1/4 of the manufacturers' maximum recommended daily dose (Max) achieved a BP lowering effect that was 60 to 70% of the BP lowering effect of Max. A dose of 1/2 Max achieved a BP lowering effect that was 80% of Max. ARB doses above Max did not significantly lower BP more than Max.

Combining the effects of maximum recommended doses and higher gives an estimate of the resting trough blood pressure lowering efficacy for ARBs as a class of drugs of -9 mm Hg (95% CI -10 to -8) for systolic blood pressure (SBP) and -6 mm Hg (95% CI -7 to -6) for diastolic blood pressure (DBP). Due to evidence of publication bias, the largest trials provide the best estimate of the trough BP lowering efficacy for ARBs as a class of drugs: -8 mm Hg for SBP and -5 mm Hg for DBP. This estimate is similar to that shown for ACE inhibitors as a class. The BP lowering effect is modestly greater 1 to 12 hours after the dose than at trough, -12/-7 mm Hg.

The review did not provide a good estimate of the incidence of harms associated with ARBs because of the short duration of the trials and the lack of reporting of adverse effects in many of the trials.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment).

    References

    • Heran BS, Wong MM, Heran IK et al. Blood pressure lowering efficacy of angiotensin receptor blockers for primary hypertension. Cochrane Database Syst Rev 2008;(4):CD003822. [PubMed].

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