Hypotensive symptoms (ACE-I vs ARB)

Q: 58 years old noncompliant male is admitted to ICU with hypertensive crisis. He has improved after intravenous infusion of anti-hypertensive. Now ICU team is considering to switch over his IV anti-hypertensive to oral. Because of his previous history of congestive heart failure (CHF) and diabetes, ACE-Inhibitor (ACE-I) or angiotensin II receptor blockers (ARBs) are under consideration. Another factor to consider is autonomic dysfunction because of his diabetes. Which group of drugs are more prone to cause hypotensive symptoms? - select one

A) ACE-Is

B) ARBs

Answer: B

ARBs have an advantage over ACE-Is when it comes to cough and angioedema. But, hypotensive symptoms are more common with ARBs.

In patients who may have underlying autonomic dysfunction (like our patient in this question), it can be severe. It may require permanent discontinuation. This effect persists for a while after discontinuation (see reference #2). A desirable 'washout period' should be taken into consideration before exposing a patient to any such other risk (see reference #3)

#hemodynamic

#pharmacology

References:

1. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358:1547.

2. Lee JH, Kim YY, Heo HJ, Kim G, Oh C. Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report. Medicine (Baltimore). 2023 Nov 24;102(47):e36126. doi: 10.1097/MD.0000000000036126. PMID: 38013296; PMCID: PMC10681524.

3. Hojo T, Shibuya M, Kimura Y, Otsuka Y, Fujisawa T. Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan. Anesth Prog. 2020 Jun 1;67(2):86-89. doi: 10.2344/anpr-67-02-02. PMID: 32633774; PMCID: PMC7342806.