Key result
ACE inhibitors and ARBs provide comparable blood pressure reduction and nephroprotection, while ARNIs offer the most confirmed advantage in eligible symptomatic patients with HFrEF.
Why the study?
To critically compare ACEIs, ARBs, and ARNIs in contemporary cardiovascular and renal care, emphasizing guideline-directed use, safety monitoring, adherence, and implementation.
Does the selection among ACEIs, ARBs, and ARNIs improve clinical outcomes and safety in patients with cardiovascular and renal diseases?
Does the selection among ACEIs, ARBs, and ARNIs improve clinical outcomes and safety in patients with cardiovascular and renal diseases?
Optimal selection of RAAS inhibitors requires matching the specific drug class to the patient's clinical phenotype, with ARNIs preferred in HFrEF, ACEIs established post-MI, and ARBs favored for tolerability in hypertension and CKD.
This narrative review critically compares angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNIs) in contemporary cardiovascular and renal care, with particular emphasis on guideline-directed use, safety monitoring, adherence, and treatment implementation. A structured narrative search of PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library was completed on 28 June 2026. Randomized trials, systematic reviews, large observational studies, target-trial emulations, and international guideline documents were prioritized. ACEIs and ARBs provide broadly comparable blood pressure reduction and nephroprotection in many populations, whereas ARBs are usually better tolerated, mainly because cough and bradykinin-mediated angioedema are less frequent. ACEIs remain particularly well established after myocardial infarction. ARNIs have the most clearly confirmed advantage in eligible symptomatic patients with HFrEF, but their benefit should not be automatically extrapolated to uncomplicated hypertension, CKD without heart failure, or post-myocardial infarction patients without a heart failure phenotype. Optimal selection requires integration of evidence, laboratory monitoring, availability, costs, and patient preferences.
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Meszka et al. (2026) conducted a review in Cardiovascular and renal diseases (HFrEF, hypertension, CKD). ACE inhibitors, Angiotensin Receptor Blockers (ARBs), and Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) was evaluated. ACE inhibitors and ARBs provide comparable blood pressure reduction and nephroprotection, while ARNIs offer the most confirmed advantage in eligible symptomatic patients with HFrEF.
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