Beta blockers and ACE inhibitors are two of the most prescribed heart and blood pressure drugs, but they work on entirely different systems in the body. One mainly acts on the heart itself, the other on the blood vessels and the hormones that squeeze them. For everyday blood pressure control they end up about even, so the real difference lies in what else each drug does to your body. That is also why many people with heart disease end up taking both.
How Each Drug Works in Your Body
Beta blockers sit on the heart’s adrenaline receptors without switching them on.1Revista Española de Cardiología (English Edition). Beta-blockers: Historical Perspective and Mechanisms of Action Adrenaline can’t push the heart as hard, so it beats slower and with less force.2Revista Española de Cardiología (English Edition). Beta-blockers: Historical Perspective and Mechanisms of Action Blood pressure falls mainly because the heart pumps less blood each minute.3PubMed. Effects of beta-blockers on glucose and lipid metabolism
ACE inhibitors go after a hormone instead. Your kidneys start a chain that ends in angiotensin II, a hormone that narrows blood vessels and makes the body hold on to salt.4Cardiovascular Pharmacology Concepts. Angiotensin Converting Enzyme (ACE) Inhibitors5PubMed. Angiotensin-converting enzyme inhibitors An enzyme called ACE carries out the final step of that chain.6Cardiovascular Pharmacology Concepts. Angiotensin Converting Enzyme (ACE) Inhibitors Block ACE and less of the hormone forms, so vessels relax.7Cardiovascular Pharmacology Concepts. Angiotensin Converting Enzyme (ACE) Inhibitors ACE also normally breaks down a substance that widens vessels, so with the enzyme blocked, that substance builds up and adds to the relaxing effect.8Cardiovascular Pharmacology Concepts. Angiotensin Converting Enzyme (ACE) Inhibitors
You can usually tell which one you take from the name. Beta blockers tend to end in -olol, like metoprolol, atenolol, and bisoprolol. ACE inhibitors tend to end in -pril, like lisinopril, enalapril, and ramipril. There are exceptions, such as carvedilol, a beta blocker despite its different ending, so check your label to know which sections apply to you.
Day to day, the two feel different. On a beta blocker, your resting pulse and your heart rate during exercise will usually be lower, and feeling less able to push hard is common at first. ACE inhibitors usually don’t change your pulse. Your home blood pressure readings are the best guide to whether either one is working.
Which Lowers Blood Pressure Better
Beta blockers and ACE inhibitors lower resting blood pressure to a similar degree.9PubMed. Comparison of beta-blockade and ACE inhibitors in the treatment of hypertension Beta blockers do hold down the rise in blood pressure during exercise more strongly.10PubMed. Comparison of beta-blockade and ACE inhibitors in the treatment of hypertension Because a beta blocker blunts adrenaline, your pressure and pulse climb less when you take the stairs or walk briskly, which an ACE inhibitor does not do.
When added as a second blood pressure drug, about 7 in 10 people reached control at a year on either one (70.5% vs 69.0%).11PubMed Central. Comparative Effectiveness of ACE inhibitors versus Beta blockers as Second-line Therapy for Hypertension Heart attacks, strokes, and later kidney disease also happened at similar rates with either second drug.12PubMed Central. Comparative Effectiveness of ACE inhibitors versus Beta blockers as Second-line Therapy for Hypertension Since both performed about equally as an add-on, the choice often rests on your other conditions and on which side effects you would rather avoid.
Neither is usually the very first pill. Many guidelines now start with an ACE inhibitor, ARB, calcium channel blocker, or water pill, and beta blockers are often reserved for people with another reason to take them.
Individual response varies. In people with a weakened heart, enalapril lowered blood pressure in white patients but not measurably in Black patients.13PubMed. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction Guidelines often favor other first choices, such as calcium channel blockers or water pills, for Black patients with high blood pressure. Genes may also shape how well each drug works, but no routine test is used to choose between them yet.14PubMed Central. Pharmacogenetic factors affecting β-blocker metabolism and response
Heart Failure and Life After a Heart Attack
After a heart attack, the heart can stretch and reshape itself, which weakens it over time.15PubMed. Effects of angiotensin converting enzyme inhibitors on remodeling in clinical trials ACE inhibitors slow this reshaping, and that is closely tied to their benefit.16PubMed. Effects of angiotensin converting enzyme inhibitors on remodeling in clinical trials In a major trial, people with severe heart failure on enalapril were 31% less likely to die within a year.17The Pharmaceutical Journal. From snake venom to ACE inhibitor — the discovery and rise of captopril After a heart attack with a weakened heart, captopril cut deaths by 20%.18The Pharmaceutical Journal. From snake venom to ACE inhibitor — the discovery and rise of captopril
Beta blockers help in another way. In a weakened heart, the body floods it with adrenaline, which damages it further.19PubMed Central. Mechanisms of the beneficial effects of beta-adrenoceptor antagonists in congestive heart failure In heart failure with reduced ejection fraction, where a weakened heart muscle pumps too little, beta blockers improve pumping, ease symptoms, and cut hospital stays and deaths.20The Cardiology Advisor. Beta Blockers in Heart Failure Management: Unlocking their Potential How much each person benefits varies widely.21PubMed Central. Polygenic Score for Beta-Blocker Survival Benefit in European Ancestry Patients with Reduced Ejection Fraction Heart Failure
Resting the heart from constant adrenaline lets it recover over months. Doctors start low and raise the dose slowly for this reason, and you may feel more tired for the first few weeks before things improve. Their actions complement each other, which is why the two drugs are often combined.22PubMed Central. The Combination of Beta-Blockers and ACE Inhibitors Across the Spectrum of Cardiovascular Diseases
Ejection fraction is the share of blood the main pumping chamber pushes out with each beat, usually measured with an ultrasound of the heart. A lower number means a weaker pump, and it is a main reason doctors choose these drugs for heart failure. If you have heart failure, ask which type you have, because the strongest evidence for both drugs applies to reduced ejection fraction.
Diabetes and Kidney Disease
ACE inhibitors lower pressure inside the kidney’s filters as well as overall blood pressure.23bpac.org.nz. Beta Blocker vs. ACE Inhibitor: What’s the Difference? That is how they slow kidney damage from diabetes.24bpac.org.nz. Beta Blocker vs. ACE Inhibitor: What’s the Difference? In people with kidney disease, benazepril cut the risk of kidney function failing badly by 53% over 3 years.25PubMed. Angiotensin-converting enzyme inhibitors and kidney protection: the AIPRI trial The benefit was largest in people leaking a lot of protein into their urine.26PubMed. Angiotensin-converting enzyme inhibitors and kidney protection: the AIPRI trial
Protein in the urine is a sign that the kidney’s filters are under strain, and a simple urine test often finds it. Even with normal kidney tests, many people with diabetes and high blood pressure are given an ACE inhibitor or its cousin the ARB.
Beta blockers can nudge blood sugar up. In people with type 2 diabetes, older beta blockers worsened blood sugar control, while enalapril improved it.27PubMed. Effects of alpha and beta adrenoceptor blocking drugs and ACE inhibitors on long term glucose and lipid control in hypertensive non-insulin dependent diabetics Atenolol raised fasting blood sugar and insulin in overweight people with high blood pressure, while an ACE inhibitor did not.28PubMed. Effects of antihypertensive therapy on glucose and insulin metabolism and on left ventricular mass: A randomized, double-blind, controlled study of 21 obese hypertensives Newer beta blockers that also widen vessels, such as carvedilol, have gentler effects on sugar and cholesterol.29PubMed. Effects of beta-blockers on glucose and lipid metabolism
If you already take a beta blocker and have diabetes, your doctor can track your long-term sugar test to see whether it is making a difference. Don’t stop it on your own because of this worry, since stopping suddenly carries its own risks.
If you have diabetes and take a beta blocker, know that it can hide the shaky, racing-heart warning signs of low blood sugar. Sweating usually still happens and can be a clue. Check your sugar more often after starting or changing a dose, and ask whether a vessel-widening beta blocker fits you.
On an ACE inhibitor, doctors usually check kidney function and potassium a week or two after you start. A small rise in creatinine is often expected and not a reason to stop. Report reduced urination or swelling.
Side Effects of Each
ACE inhibitors are generally well tolerated but can cause a persistent dry cough in some people.30PubMed. Pathophysiology of cough with angiotensin-converting enzyme inhibitors: How to explain within-class differences? The built-up vessel-widening substance irritates nerve endings in the airways, so lowering the dose doesn’t usually stop it.31PubMed. ACE Inhibitor Cough and Angioedema: Practical Management Rarely, they cause swelling of the lips, tongue, or throat, which is not an allergy.32PubMed. ACE Inhibitor Cough and Angioedema: Practical Management Swelling of the face or throat needs emergency care.
The cough is dry and tickly, without mucus or fever. It can start weeks or even months after you begin the drug and usually fades within weeks of stopping. Mention it to your doctor rather than buying cough syrup.
Common bothersome effects of beta blockers include tiredness, muscle weakness, cold hands and feet, nightmares, and erection problems.33PubMed. How disturbing are side effects of beta blockers They can also trigger wheezing, an overly slow pulse, depression, and leg pain on walking.34PubMed. Beta-adrenergic receptor blockers. Adverse effects and drug interactions
Fatigue is often worst in the first weeks. Taking the pill at night may help if dizziness bothers you, though that may make nightmares more noticeable; nightmares may improve with a different beta blocker. Sexual side effects are worth raising with your doctor, because options exist.
If an ACE inhibitor causes cough, the usual switch is an ARB (an ACE inhibitor’s close cousin) or a calcium channel blocker.35PubMed Central. Angiotensin‐converting enzyme inhibitor induced cough compared with placebo, and other antihypertensives: A systematic review, and network meta‐analysis ARBs work as well but cause far less cough and swelling.36PubMed. Overcoming Cough and Angioedema: Advocating for the Use of ARBs Over ACE Inhibitors
Who Should Avoid Each Drug
ACE inhibitors can harm a developing baby, so they aren’t used in pregnancy.37Journal of the American Society of Nephrology. Renal Artery Stenosis in Early High-Risk Pregnancy Anyone who could become pregnant should discuss birth control or plans before starting. If you become pregnant while taking one, contact your doctor right away rather than stopping without a plan.
They’re also avoided in narrowing of both kidney arteries, because kidney function can drop sharply.38PubMed. Safety of angiotensin-converting enzyme inhibitors in patients with bilateral renal artery stenosis following successful renal artery stent revascularization When both arteries feeding the kidneys are narrowed, the kidneys rely on the vessel-tightening hormone to keep up filtering pressure. Blocking it removes that support. Doctors may look for this narrowing if blood pressure is hard to control, or if kidney tests worsen quickly after starting an ACE inhibitor.
Beta blockers are avoided with a very slow pulse, some heart rhythm blocks, and severe liver problems.39The Cardiology Advisor. Beta Blockers Non-selective types are also avoided in asthma, and used cautiously in COPD, because they can tighten airways.40Cardiovascular Pharmacology Concepts. Beta-Adrenoceptor Antagonists
Taking Both and Stopping Safely
Each drug targets a different system, so their effects add together. Dizziness on standing can be more likely, so rise slowly. Pill organizers and phone reminders help, and never double up after a missed dose without checking.
Stopping a beta blocker abruptly can cause a rebound of racing heart, high blood pressure, chest pain, and sweating.41Consensus. Beta Blocker Withdrawal Effects – Consensus Academic Search Engine Symptoms usually appear within a few days.42Consensus. Beta Blocker Withdrawal Effects – Consensus Academic Search Engine In people with heart disease this can raise heart attack risk.43Consensus. Beta Blocker Withdrawal Effects – Consensus Academic Search Engine Doses should be tapered with your doctor.
Tapering means lowering the dose in steps over days to weeks. During a taper, you may be asked to avoid strenuous exercise and to report chest pain or a racing heart.
If you’re ill with vomiting or can’t keep pills down, call your doctor or pharmacist rather than just skipping the beta blocker. Request refills before you run out, since a gap of a few days is enough to cause rebound effects.
Skipped doses are common. After a heart attack, about 3 in 10 people didn’t take their ACE inhibitor or ARB regularly, and about 1 in 4 skipped their beta blocker.44PubMed Central. Adherence Trade-off to Multiple Preventive Therapies and All-Cause Mortality after Acute Myocardial Infarction If side effects make you want to skip, ask about switching instead.