Lower rate of side effect with angiotensin-converting enzyme inhibitors: How to explain within-class differences?

New evidence published in January 2023, highlights current evidence on the incidence and mechanisms of cough associated with ACEi use and consider how to manage ACEi-related cough in clinical practice.

ACEi efficacy has been proven in patients with hypertension, coronary artery disease, and heart failure with and without concomitant diabetes and/or chronic kidney disease with a favourable tolerability profile with cough as the only relevant adverse event

In the presence of cough, the current strategy suggested by most guidelines is to switch from an ACEi to an ARB.

Patients who experience any dry cough with ACEi are often switched to ARB or other classes of antihypertensive drugs, regardless of cough severity. The incidence of varies among individual ACEi:

Perindopril, which has a high tissue ACE affinity, is associated with a lower rate of cough among ACEis and demonstrated extensive evidence supporting its cardiovascular benefits and tolerability

Clinical implications

Incidence of cough should not be considered a class effect for ACEi and ACEis that induce cough less frequently should be preferred

In clinical practice, need to avoid inappropriate discontinuation of ACEi

the patient may benefit by a switch from one ACEi to another a challenge/re-challenge

should be performed in patients with incident cough to determine if re-introduction of ACEi is associated with recurrence of symptoms

Every effort should be made to enable patients to continue ACEi therapy to reduce adverse CV outcomes and improve survival

Perindopril is associated with a relatively low incidence of cough among ACEis combined with extensive evidence supporting its CV benefits and tolerability

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SCAC 01/23 DM 023 SERVIER-For the exclusive use of the health care professional