High blood pressure doesn’t always cause symptoms, but it’s quietly increasing your risk of heart attack, stroke, and kidney damage. That’s why doctors prescribe antihypertensive meds - not to make you feel better right away, but to keep you alive longer. Three of the most common classes are beta-blockers, ACE inhibitors, and ARBs. Each works differently, has different side effects, and fits different patients. Knowing how they compare can help you understand why your doctor chose one over another - or why you might need to switch.
How ACE Inhibitors Work - and Why So Many People Quit Them
ACE inhibitors like lisinopril, enalapril, and ramipril have been the go-to for hypertension since the 1980s. They block the enzyme that turns angiotensin I into angiotensin II - a chemical that tightens blood vessels and raises blood pressure. By stopping this, they relax arteries, reduce fluid retention, and lower pressure. But here’s the catch: they also cause bradykinin to build up. That’s a harmless substance under normal conditions, but in some people, it triggers a dry, hacking cough.
Studies show 10-20% of people on ACE inhibitors develop this cough. For some, it’s mild. For others, it’s constant, sleep-disrupting, and unbearable. One patient from Melbourne told me, "I was on lisinopril for six months. Every night, I’d wake up coughing. I thought I had a cold. Turns out, it was the pill." That’s why, according to CVS Health data from 2021, 78% of people who stop ACE inhibitors do so because of cough. And when they switch to an ARB, 89% of those cases resolve.
ACE inhibitors also carry a small but serious risk: angioedema - swelling of the face, lips, or throat. It happens in less than 1% of users, but when it does, it’s an emergency. That’s why doctors don’t prescribe them to people with a history of this reaction. Still, for patients with diabetes and kidney protein leakage (albuminuria), ACE inhibitors are the gold standard. The RENAAL trial showed they cut proteinuria by 21% more than ARBs, protecting kidney function better than any other class.
ARBs: The Tolerable Alternative
ARBs - angiotensin receptor blockers - like losartan, valsartan, and candesartan, do the same job as ACE inhibitors but without the cough. Instead of blocking the enzyme, they block the receptor that angiotensin II binds to. No bradykinin buildup. No cough. No angioedema. That’s why, in 2021, a real-world study of over 300,000 patients found ARBs had half the risk of angioedema and a 38% lower chance of cough compared to ACE inhibitors.
They’re just as effective at lowering blood pressure. In fact, ARBs reduce systolic pressure by 10-15 mmHg and diastolic by 6-8 mmHg - the same as ACE inhibitors. And while ACE inhibitors were long seen as "first-line," newer guidelines from the AHA and ESC now treat them as equals. Many cardiologists today start new patients on ARBs simply because they’re better tolerated.
One big advantage? Persistence. A 2021 analysis of 2 million patients showed 63% stayed on ARBs after 12 months. Only 57% stayed on ACE inhibitors. The reason? Fewer side effects. Patient reviews on Drugs.com give ARBs a 7.1/10 rating versus 5.8/10 for ACE inhibitors. Reddit threads are full of posts like: "Switched from lisinopril to valsartan - cough vanished in three days. Best decision I ever made."
Beta-Blockers: Not for Everyone - But Essential for Some
Beta-blockers like metoprolol, carvedilol, and bisoprolol work differently. Instead of relaxing blood vessels, they slow the heart. They reduce heart rate by 10-15 beats per minute and lower cardiac output. That’s why they’re not the first choice for general high blood pressure. Studies like the INVEST trial showed they’re worse than calcium channel blockers at preventing strokes.
But here’s where they shine: after a heart attack. The COMMIT trial found beta-blockers cut cardiovascular death by 23% in post-MI patients. That’s why they’re still first-line after a heart attack - even if the patient doesn’t have heart failure. The same goes for heart failure with reduced ejection fraction (HFrEF). Carvedilol cut all-cause mortality by 35% in the COPERNICUS trial. Atenolol? Not so much. It showed no mortality benefit in the LIFE trial. That’s why doctors now avoid atenolol for routine hypertension.
The downside? Fatigue. Up to 28% of people on beta-blockers feel exhausted. One user wrote: "Metoprolol made me so tired I couldn’t work. Switched to amlodipine - energy came back." Some beta-blockers are worse than others. Non-selective ones like propranolol can trigger asthma attacks. Even selective ones like metoprolol can raise triglycerides and lower HDL ("good" cholesterol) by 5-10%. But newer agents like nebivolol cause less fatigue - only 14% report it versus 28% with metoprolol.
What About Combining Them?
Many people need more than one drug. Combining an ACE inhibitor or ARB with a thiazide diuretic (like hydrochlorothiazide) is common and effective. Together, they can drop systolic pressure by 20-25 mmHg - more than either alone.
But there’s one dangerous combo to avoid: ACE inhibitor + ARB. The ONTARGET trial in 2008 proved this doubles the risk of kidney failure, high potassium, and low blood pressure. No benefit. Just harm. So if you’re on one, don’t add the other.
Now, a new option is emerging: sacubitril-valsartan (Entresto). It’s not just an ARB - it’s an ARB paired with a neprilysin inhibitor. The PARADIGM-HF trial showed it beat enalapril (an ACE inhibitor) in heart failure patients, reducing death by 20%. It’s now recommended as first-line for HFrEF by the European Heart Failure Association. But it carries a slightly higher risk of angioedema (0.5% vs 0.2%) - so it’s not for everyone.
Which One Should You Be On?
There’s no one-size-fits-all. Here’s how doctors decide:
- Diabetes + kidney disease → ACE inhibitor (best kidney protection)
- Post-heart attack → Beta-blocker (proven to save lives)
- Heart failure with reduced ejection fraction → Sacubitril-valsartan (if eligible), otherwise ACE inhibitor or ARB
- General high blood pressure with no other conditions → ARB (better tolerability) or ACE inhibitor (if cost is a factor)
- Side effects from ACE inhibitor → Switch to ARB - it’s almost always the fix
- Fatigue from beta-blocker → Try nebivolol or switch to calcium channel blocker
Start doses matter too. Most patients begin with lisinopril 10 mg, losartan 50 mg, or metoprolol succinate 25 mg. These are adjusted slowly. Don’t expect instant results - it takes weeks. And never stop these meds without talking to your doctor. Suddenly stopping beta-blockers can trigger a heart attack.
What’s Changing in 2026?
Guidelines keep evolving. The 2023 AHA guidelines now suggest ARBs over ACE inhibitors for new patients needing renin-angiotensin system blockade - unless they have post-MI or diabetic kidney disease. The PRECISION trial (due to finish in 2025) is studying whether ARBs protect brain health better than ACE inhibitors in older adults. Early data suggests ARBs may slow cognitive decline.
Market trends reflect this shift. ARBs are growing faster than ACE inhibitors. By 2028, they’re expected to lead the hypertension market. But ACE inhibitors won’t disappear. They’re still irreplaceable in heart attack recovery and diabetic kidney care.
And the future? Fixed-dose combos are coming. In 2023, the FDA approved a four-drug pill for hard-to-treat hypertension. It combines an ARB, two diuretics, and a calcium blocker. That’s the next frontier: fewer pills, better control, fewer side effects.
Can I switch from an ACE inhibitor to an ARB if I have a cough?
Yes - and it’s the most common solution. If you develop a persistent dry cough from an ACE inhibitor, switching to an ARB like losartan or valsartan usually eliminates the cough within days. Studies show 89% of patients who stop ACE inhibitors due to cough find relief with ARBs. There’s no drop in blood pressure control, and the risk of serious side effects like angioedema is much lower.
Why aren’t beta-blockers used as first-line for high blood pressure anymore?
Because they’re less effective at preventing strokes compared to other drugs like ARBs, ACE inhibitors, or calcium channel blockers. Trials like INVEST showed higher stroke rates with atenolol. They also tend to cause fatigue, weight gain, and worsen blood sugar and cholesterol levels. Today, beta-blockers are reserved for specific cases: after a heart attack, in heart failure, or if other drugs aren’t tolerated.
Is it safe to take an ARB and a beta-blocker together?
Yes - and it’s often recommended. Many patients with heart failure or high blood pressure plus other conditions (like diabetes or past heart attack) need multiple drugs. Combining an ARB with a beta-blocker like carvedilol or bisoprolol is standard practice. This combo reduces strain on the heart from two angles: relaxing blood vessels and slowing heart rate. It’s well-studied and proven to improve survival.
Do ARBs cause less fatigue than beta-blockers?
Yes. ARBs are generally energy-neutral. Most people don’t report fatigue from them. Beta-blockers, especially older ones like metoprolol, cause fatigue in up to 28% of users. If you’re tired on a beta-blocker, switching to an ARB might help - especially if your main issue is high blood pressure without heart failure. Always check with your doctor before switching.
What’s the most common reason people stop taking their blood pressure medication?
Side effects. For ACE inhibitors, it’s cough. For beta-blockers, it’s fatigue or dizziness. For ARBs, it’s rare - only about 15% report any side effects. That’s why adherence is highest with ARBs. One study found 63% of patients stayed on ARBs after a year, compared to just 57% on ACE inhibitors. If you’re struggling with side effects, talk to your doctor. There’s almost always a better option.
Final Thoughts
There’s no "best" antihypertensive. What works for your neighbor might not work for you. The goal isn’t just lowering numbers - it’s staying healthy, avoiding hospital visits, and living without side effects that ruin your day. ACE inhibitors save lives in heart attack and kidney disease. ARBs are easier to live with for most people with plain high blood pressure. Beta-blockers are lifesavers after a heart attack - but not for everyday use. The right choice depends on your history, your symptoms, and your goals. Don’t just take what’s prescribed - ask why. And if something feels off, speak up. There’s always a better fit.
