When you’re first diagnosed with high blood pressure, your doctor might hand you a prescription for one of three common drugs: a beta-blocker, an ACE inhibitor, or an ARB. They all lower blood pressure, but they work in totally different ways - and not all of them are right for everyone. Some people feel fine on one, while others end up with a dry cough, fatigue, or worse. Understanding how these three classes differ can help you ask better questions and make smarter choices about your treatment.
How ACE Inhibitors Work - And Why Some People Can’t Tolerate Them
ACE inhibitors like lisinopril, enalapril, and ramipril have been around since the 1980s. They block an enzyme that turns angiotensin I into angiotensin II, a chemical that tightens blood vessels. Less angiotensin II means relaxed arteries, lower blood pressure, and less strain on the heart. They’re especially helpful if you have diabetes, kidney disease, or have had a heart attack. The HOPE trial showed they cut major heart events by 20-25% in high-risk patients.
But there’s a catch. By blocking this enzyme, ACE inhibitors cause bradykinin to build up. That’s great for blood vessels, but it also irritates the lungs. About 10-20% of people develop a persistent, dry cough - not a cold, not allergies, just a nagging cough that won’t go away. In 0.1-0.7% of cases, it can lead to angioedema, a dangerous swelling of the face or throat. One 2021 study of over 300,000 patients found that ARBs caused less than half the cough and angioedema risk compared to ACE inhibitors.
On Drugs.com, lisinopril has a 5.8 out of 10 average rating. Over 40% of users report cough, and nearly 1 in 10 stop taking it because of side effects. Reddit threads are full of posts like: “Switched from lisinopril to valsartan after six months of coughing - felt like a new person.”
ARBs: The Better-Tolerated Alternative
ARBs - angiotensin receptor blockers - like losartan, valsartan, and candesartan, came onto the scene in the mid-1990s. They work at the other end of the same pathway. Instead of blocking the enzyme, they block the receptor that angiotensin II binds to. That means they still lower blood pressure just as well, but without messing with bradykinin.
The result? Far fewer coughs. In the same 2021 study, ARB users had only a 6.4% cough rate compared to 11.7% for ACE inhibitors. Angioedema risk dropped by nearly half. Patient reviews on Drugs.com show losartan with a 7.1 out of 10 rating - significantly higher than lisinopril. A 2021 CVS Health analysis found that 63% of people stayed on ARBs after 12 months, compared to just 57% on ACE inhibitors. The main reason? Side effects.
Even more surprising, some research suggests ARBs might be better for brain health. A 2021 study linked ARBs to slower cognitive decline in older adults, with a 18% lower risk of dementia over five years. That’s why some experts now argue ARBs should be the first choice for most people with hypertension - not just those who can’t tolerate ACE inhibitors.
Beta-Blockers: Slowing Down the Heart
Beta-blockers like metoprolol, carvedilol, and bisoprolol don’t relax blood vessels. Instead, they slow your heart rate and reduce the force of each beat. This lowers blood pressure and reduces the heart’s oxygen demand. They’re not typically used as first-line treatment for simple high blood pressure anymore - but they’re essential for certain situations.
If you’ve had a heart attack, beta-blockers cut your risk of dying from another one by 23%. In heart failure with reduced ejection fraction (HFrEF), carvedilol cuts overall death risk by 35%. These aren’t small numbers. That’s why cardiologists still reach for them in these cases.
But they come with trade-offs. Many people feel tired, sluggish, or even depressed on beta-blockers. One study found 28% of users reported fatigue - enough to make them quit. Non-selective beta-blockers (like propranolol) can also worsen asthma or trigger bronchospasm. Even the more selective ones, like metoprolol, can raise triglycerides and lower HDL (the “good” cholesterol), which isn’t ideal for people with diabetes or metabolic syndrome.
There’s a better option: nebivolol. It’s a newer beta-blocker that causes fewer fatigue symptoms (only 14% vs 28%) and doesn’t hurt cholesterol levels. It’s not always covered by insurance, but if you’re struggling with tiredness on metoprolol, it’s worth asking about.
Which One Should You Take?
There’s no one-size-fits-all answer. Your best choice depends on your health history.
- If you have diabetes or kidney disease with protein in your urine, ACE inhibitors are still the gold standard - they slow kidney damage better than ARBs.
- If you’re new to treatment and don’t have those conditions, ARBs are often a better fit. They work just as well, with fewer side effects.
- If you’ve had a heart attack or have heart failure, beta-blockers (especially carvedilol or bisoprolol) are critical - don’t skip them.
- If you’re over 65 and worried about memory, ARBs might offer extra brain protection.
- If you’re a smoker or have asthma, avoid non-selective beta-blockers.
And here’s something many doctors don’t tell you: you don’t have to stay on the first drug you’re given. If you get a cough on lisinopril, switching to valsartan usually fixes it. If you’re exhausted on metoprolol, try nebivolol. If you’re still not at your target blood pressure, adding a low-dose diuretic (like hydrochlorothiazide) often does the trick - and it’s safer than doubling up on ACE inhibitors and ARBs.
What About Combining Them?
Some patients think taking two blood pressure drugs from the same family will work better. That’s not true - and it can be dangerous.
Combining an ACE inhibitor and an ARB was once common. But the ONTARGET trial in 2008 showed it increased kidney failure risk by 38% without lowering heart attack or stroke rates. Today, that combo is avoided entirely.
But combining different classes? That’s standard. Most people need two or three drugs to reach their goal. A common, safe combo is an ARB plus a diuretic, or a beta-blocker plus a calcium channel blocker like amlodipine. Newer fixed-dose pills - like amlodipine/valsartan/hydrochlorothiazide - make it easier to take multiple medications in one pill.
What to Watch For
Each class has red flags you should know:
- ACE inhibitors: Dry cough, swelling in lips/tongue, sudden drop in kidney function (watch for fatigue, swelling in legs).
- ARBs: Rare, but still possible angioedema. Also, avoid if you’re pregnant - they can harm the fetus.
- Beta-blockers: Extreme tiredness, dizziness, cold hands/feet, worsening asthma, or unexplained weight gain (could mean fluid buildup).
If you notice any of these, don’t stop the drug cold. Call your doctor. Some side effects fade after a few weeks. Others need a switch.
Real-World Trends
In 2023, lisinopril was still the most prescribed blood pressure drug in the U.S. - over 129 million prescriptions. But ARBs are catching up fast. Their market is growing at 4.2% per year, while ACE inhibitors are growing at just 2.8%. Why? Because patients are demanding better tolerability.
Cardiologists are already ahead of primary care doctors in switching to ARBs. In one survey, 68% of cardiologists now prescribe ARBs as their first renin-angiotensin drug for new patients - compared to just 32% of general practitioners. That gap is closing. The 2023 AHA guidelines now say ARBs are just as good as ACE inhibitors for most people with high blood pressure.
And the future? We’re moving toward personalized treatment. Genetic tests might one day tell you whether you’re more likely to get a cough on ACE inhibitors. For now, though, the best advice is simple: if one drug doesn’t work for you, another one might.
Can I switch from an ACE inhibitor to an ARB if I get a cough?
Yes, absolutely. A dry cough is the most common reason people stop taking ACE inhibitors. Switching to an ARB like losartan or valsartan usually eliminates the cough within days to weeks. Studies show 89% of patients who switch due to cough no longer have the problem. There’s no loss in blood pressure control - and you’re less likely to have other side effects like swelling.
Are beta-blockers safe for people with diabetes?
They can be, but with caution. Beta-blockers can mask symptoms of low blood sugar (like shakiness or a fast heartbeat), which is dangerous. They can also raise triglycerides and lower HDL cholesterol. If you have diabetes, ARBs or calcium channel blockers are often preferred as first-line. But if you’ve had a heart attack or have heart failure, beta-blockers are still essential - your doctor will monitor your blood sugar closely.
Why do some doctors still prescribe ACE inhibitors over ARBs?
Because for certain conditions, ACE inhibitors have stronger evidence. If you’ve had a heart attack, have diabetic kidney disease, or have heart failure, ACE inhibitors have been shown to save more lives in long-term trials. ARBs are excellent alternatives, especially for tolerability, but in these specific cases, ACE inhibitors remain the gold standard. The choice isn’t about which is better overall - it’s about which is better for your situation.
Do these drugs affect kidney function?
Yes - but in different ways. Both ACE inhibitors and ARBs protect the kidneys in people with diabetes or proteinuria by reducing pressure inside the filtering units. That’s why they’re recommended for kidney disease. But in people with narrowed kidney arteries or severe kidney failure, they can cause a sudden drop in kidney function. That’s why doctors check your creatinine and potassium levels before and after starting them. If your creatinine rises more than 30% in the first few weeks, your dose may need adjusting.
Is it true that ARBs are better for older adults?
Evidence suggests they might be. A 2021 study found older adults on ARBs had a lower risk of cognitive decline compared to those on ACE inhibitors. This may be because ARBs don’t increase bradykinin, which can cause inflammation in the brain. While more research is coming (like the ongoing PRECISION trial), many experts now consider ARBs a smart first choice for patients over 65, especially if they’re at risk for memory problems.