Cough Induced by Angiotensin-Converting Enzyme Inhibitors Versus Angiotensin II Receptor Blockers in Arterial Hypertension: Incidence, Pathophysiological Mechanisms and Impact on Therapeutic Adherence
DOI:
https://doi.org/10.66201/ss.v1.13Keywords:
Cough, High Blood Pressure, Ace Inhibitors, Angiotensin II Receptor Blockers, Therapeutic Adherence, Bradykinin, TolerabilityAbstract
Background: Dry cough is the most common adverse effect of angiotensin-converting enzyme (ACE) inhibitors. Its primary mechanism is the accumulation of bradykinin and substance P in the bronchial epithelium. This class effect reduces treatment adherence in hypertension, a condition affecting more than 1.28 billion adults worldwide.
Aim: To synthesize the available evidence (2020–2026) on the comparative incidence of cough and its impact on treatment discontinuation between ACE inhibitors and angiotensin II receptor blockers (ARBs) in adult patients with hypertension.
Methodology: An integrative literature review (PRISMA 2020 statement) was conducted with systematic searches in PubMed/MEDLINE, LILACS, and Web of Science. Randomized controlled trials (RCTs), systematic reviews, meta-analyses, and observational studies published between January 2020 and March 2026 were included. Of the 119 studies identified, 45 were selected.
Results: Meta-analyses report a cough incidence of 9.9% with ACE inhibitors versus 3.2% with ARBs, with an absolute risk difference of 6.7%. The risk of discontinuation due to cough was approximately 5 times higher with ACE inhibitors. The largest multinational cohort study (n > 2,900,000) confirmed that ARBs have lower rates of angioedema, cough, pancreatitis, and gastrointestinal bleeding, with equivalent cardiovascular efficacy.
Conclusion: Current evidence is strong and consistent: ACE inhibitors are associated with a clinically significant incidence of cough, with a risk of discontinuation up to 5 times higher than that of ARBs. These findings support the preferential selection of ARBs in patients with hypertension where therapeutic adherence is a clinical priority.
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Copyright (c) 2026 Taysa Rodrigues da Silva, Heloísa Alvino Kniphoff da Silveira, Igor Santiago Lourenço Conde, Kauan Souza, Julia Santana Antunes, Mariana De Souza Almeida, Ana Clara Martins Cavalcante, Mariana Caroline De Oliveira Torquato, Ana Carolina Gimenez Bublitz, Beatriz Oliveira de Siqueira, Yanka Ramos Borges, Andrea Paola Britos Gómez (Autor/a)
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