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Angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers are both popular and effective antihypertensive agents that work equally well for people with essential hypertension, according to a systematic review of 61 comparative studies. The evidence so far suggests the only difference between these drug classes is a higher risk of cough associated with angiotensin converting enzyme inhibitors (9.9% v 3.2% in a pooled analysis of 26 randomised trials). But as usual the evidence is full of holesholes.
Most studies lasted less than six months, side effects were reported inconsistently, and data on outcomes that matter such as death, cardiovascular events, renal failure, and angio-oedoema were too infrequent to be analysed reliably. The authors found no differences between the drug classes for any of these outcomes. But moderate differences may still exist, particularly for subgroups of patients—such as those with heart failure or diabetes—who were excluded from many studies. Only big expensive trials that go on for years not months will settle the matter either way. The authors and a linked editorial agree that at least one further trial is justified.