Gan MI Wang GM, Liang Jin Li, Linyi Fan, Meng Xu, Wen Lu Tang, James M Wright

Key messages

• The available evidence from short‐term studies suggests there is probably little to no difference between renin inhibitors and angiotensin receptor blockers in terms of death rates, withdrawal due to unwanted effects, serious unwanted events, unwanted events, and blood pressure control for people with mild primary hypertension.
• Due to a lack of strong evidence from long‐term studies, any potential differences between these two drugs for measures of heart and blood vessel health are unknown.
• Larger studies of longer duration are needed, which include a wider range of people and focus on measures of heart and blood vessel health

What is hypertension?  

Primary hypertension, also known as essential hypertension, is the kind of high blood pressure that starts on its own and is not caused by another health problem. Hypertension increases the risk of stroke, heart attack, and kidney disease. Hypertension guidelines recommend angiotensin receptor blockers (ARBs) as the first choice of treatment for people with hypertension, but do not make specific recommendations for renin inhibitors. 

What did we want to find out?  

We wanted to find out if renin inhibitors are better than ARBs for people with primary hypertension. What did we do? We searched for studies that examined renin inhibitors compared with ARBs in people with primary hypertension. We compared and summarised their results, and rated our confidence in the evidence based on factors such as study methods and sizes. 

What did we find?  

We included 11 studies involving 6780 people, with an average age range of 52 to 59 years, who had mild primary hypertension and no heart problems. The studies lasted between four weeks and nine months. All the studies compared aliskiren, a type of renin inhibitor, with an ARB. The particular ARB used was losartan in four studies, valsartan in three studies, irbesartan in three studies, and telmisartan in one study. The available evidence from short‐term studies suggests little to no difference between renin inhibitors and ARBs in people with mild primary hypertension in terms of death rates, withdrawal due to unwanted effects, serious unwanted events, unwanted events, and blood pressure control. We found no data for end‐stage renal disease.

What are the limitations of the evidence?  

Confidence is limited because of concerns about how some of the studies were conducted. There are not enough studies to be certain about the death rate results. The authors are less confident about the diastolic blood pressure results because the results of one study differed from the results of the others.

How current is the evidence?  

The evidence is current to January 2024.

Read the review: Renin inhibitors versus angiotensin receptor blockers for primary hypertension

Wang GM, Li LJ, Fan L, Xu M, Tang WL, Wright JM. Renin inhibitors versus angiotensin receptor blockers for primary hypertension. Cochrane Database of Systematic Reviews 2025, Issue 2. Art. No.: CD012570. DOI: 10.1002/14651858.CD012570.pub2. Accessed 27 February 2025.