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Best ACE Inhibitor

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  • Best ACE Inhibitor

    Two weeks ago I switched to perindopril from lisinopril, which I had taken for at least 15 years. My BP was frequently above 140/80 and it seems to be slightly lower now. Today I increased my dosage of perindopril to 8 mg. I have significant atherosclerosis which I am treating with diet (LCHF/Keto), lifestyle (bicycling), medication (20 mg Crestor, niacin), and supplements (Aged Garlic Extract, Chondroitin Sulfate). I am 71 years old and have an Lp-PMA2 activity of 137 (high risk as determined by Quest) and latest CT calcium score of 267. I hope to prevent a stroke as well using a more effective ACE inhibitor.

    This article seems to show that perindopril induces the production of the most nitric oxide in comparison with 4 other ACE inhibitors.
    (enalapril, perindopril, quinapril, ramipril, and trandolapril)

    Therapeutic modulation of the nitric oxide: all ace inhibitors are not equivalent

    Of course, it would be good to know how much they may help reduce arterial inflammation, if at all.

    This second article seems to show that perindopril is the preferred ACE inhibitor:
    Not all angiotensin-converting enzyme inhibitors are equal: focus on ramipril and perindopril.

    The abstract states:
    In patients with or at high risk for coronary heart disease who do not have heart failure, or in patients with heart failure with preserved ejection fraction, perindopril should be among the preferred treatment agents in the ACE inhibitor class. Ramipril has an impressive track record of improving cardiovascular outcomes, too, and should be considered a preferred agent among the ACE inhibitor class.

    And here is the conclusion of the article:
    Perindopril has been shown to have a longer duration of action, higher lipophilicity, and stronger tissue ACEinhibiting properties compared with other ACE inhibitors. Moreover, there are several clinical trials supporting the CV benefit of perindopril therapy in many clinical settings (eg, patients with AMI, those with HF and preserved EF, patients with or at high risk for CHD without HF). Thus, perindopril should be considered as a first-choice ACE inhibitor for treatment of patients with HF and preserved EF and in patients with or at high risk for CHD without HF.
    Perindopril and ramipril are the only ACE inhibitors to show a reduction in CV event rates in patients with or at high risk for CHD with normal LV function. Therefore, in this patient population, these two agents should be first-choice ACE inhibitor therapy. Although ramipril has demonstrated excellent ability to improve patient clinical outcomes, most of the trials were completed decades ago, prior to the current era of optimal medical therapies. Only use of the ACE inhibitor perindopril has demonstrated clear reductions in CV endpoints in patients who have been treated in ways that are reflective of current-day intensive practice (ie, on optimal medical therapy and at a lower baseline risk of CV events compared with patients receiving ramipril in HOPE). Moreover, perindopril is the only ACE inhibitor with evidence for improving morbidity and mortality rates in patients with HF who have a preserved EF. Therefore, in patients with or at high risk for CHD (without HF) and HF with preserved EF, perindopril should be strongly considered as first-choice ACE inhibitor, perhaps even prior to ramipril use.

  • #2
    Fatmax: Getting your blood pressure to below 120/80 is essential as well as getting your A1c to 5.0 or below, and BMI below 25 is also essential. I had blood pressure numbers higher than you and I am now nearly off Lisinopril altogether. As my weight dropped from going low carb and doing high intensity intervals, my blood pressure dropped to about 115/65 on an average at the same time. Blood pressure meds are useful but lifestyle and diet are more powerful.


    • #3
      Dr. Malcolm Kendrick recommends perindopril:

      "If you must take a medication, go for perindopril (raises nitric oxide most of all)."

      However, it is expensive. And I had a hard time convincing my VA PCP to write a prescription for it.
      The VA is the most backward health organization in the country. Nearly every man in the waiting room appears to have T2DM,
      and the stupid VA won't diagnose or treat it.
      Last edited by fatmax; 10-24-2018, 03:27 AM.


      • #4
        Kendrick did not provide any reference. Other ACEi’s raise NO as well. Enalapril, quinapril, ramipril, and trandolapril also do. Consider ramipril.

        Here is some good research on Perindopril. While this study showed benefits, it did not show how it compared to other ACEi’s.


        • #5
          The advantages of perindopril versus other ACE inhibitors are listed in this article:
          Not all angiotensin-converting enzyme inhibitors are equal: focus on ramipril and perindopril.

          Click the photo.


          • #6
            fatmax: That is a great citation. Thank you.