These statistics underscore the necessity of proactive management strategies to avert long-term health consequences, as poorly controlled hypertension contributes substantially to cardiovascular disease (CVD) and overall mortality.

Only 26% of South African men are aware of their blood pressure (BP) status, and treatment and control rates for both genders falling <30%. Around 40% of adults are hypertensive, but only 9% achieve adequate control. The problem is particularly pronounced among South African patients of African descent, who face a more than threefold increase in mortality rates due to hypertension-related complications compared to their counterparts of European descent.

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) are integral components of hypertension management, offering avenues to lower BP and reduce CV risk.

The British Hypertension Society has outlined a treatment algorithm that is particularly beneficial in diverse patient populations. For patients <55-years, initial treatment involves either an ACEi or a low-cost ARB, while those >55-years or of African or Caribbean descent are advised to start with a calcium channel blocker (CCB). This structured approach enhances the likelihood of effective BP control, reducing long-term risks associated with hypertension.

Efficacy and safety of ACEi vs ARBs

Both ACEi and ARBs are effective in managing hypertension, however, they exhibit different side effect profiles. ACEi are associated with a higher incidence of complications, including cough and angioedema, which can lead to non-adherence to treatment.

In contrast, ARBs typically offer a more favourable safety profile with fewer adverse effects. Notably, reports of increased myocardial infarction risks are less common with ARBs, making them a preferred choice in many cases.

In patients with impaired renal function, ACEi can cause a transient increase in creatinine levels but may offer long-term renal protection. In individuals with conditions like aortic stenosis or hypertrophic obstructive cardiomyopathy, caution is warranted due to the risk of exacerbating outflow obstruction.

Clinicians must be vigilant about drug interactions when prescribing these medications:

• Combination with other RAAS Blockers: Concurrent use of ACEi and ARBs is generally not recommended.
• Diuretics: The combination may increase the risk of hyperkalemia, particularly with potassium-sparing diuretics.
• Non-steroidal anti-inflammatory drugs: These can reduce the efficacy of ACEi and increase the risk of renal complications.

Patients living with diabetes may experience interactions between ACEi or ARBs and dipeptidyl peptidase 4 (DPP-4) inhibitors. While ACEi can be combined with DPP-4 inhibitors, careful monitoring is necessary due to potential BP increases.

Optimising hypertension treatment

Given that only 10% of hypertensive patients currently achieve target BP control, the inclusion of both ACEi and ARBs is crucial. ACEi are often more cost-effective and accessible in resource-limited settings, while ARBs are recommended as first-line treatment for patients of African descent living with hypertension due to their efficacy and lower risk of adverse effects.

Moreover, when considering chronic obstructive pulmonary disease, ARBs are preferred since ACE inhibitors may exacerbate cough, complicating clinical assessments.

Patient-centric approaches

Tailoring treatment strategies based on individual patient characteristics, drug availability, and tolerability is vital. Combining long-acting medications and utilising single-pill combinations can enhance adherence and simplify treatment regimens. Regular monitoring and patient education are essential to achieving effective hypertension management.

Conclusion

Hypertension management in South Africa demands a nuanced understanding of the roles of ACEi and ARBs. Individualised treatment approaches that consider patient demographics, comorbidities, and potential side effects are crucial for optimising outcomes. By prioritising effective strategies and addressing the unique challenges faced by diverse populations, healthcare providers can significantly improve hypertension control, ultimately reducing the burden of this critical health issue.

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