The first-line surgical approach for isolated aortic coarctation is currently the extended end-to-end anastomosis via a left posterolateral thoracotomy, as it avoids the use of patches or allografts and effectively addresses distal aortic arch hypoplasia. Alternative techniques, such as aortoplasty with patch, subclavian flap aortoplasty, and extra-anatomic grafts, were more common in previous decades but are now reserved for specific anatomies. In cases involving aortic arch hypoplasia, median sternotomy should be preferred to facilitate extended aortic arch reconstruction up to the first brachiocephalic vessel.

Complex anatomical cases may require more extensive reconstruction trough a sternotomic access, that currently is needed in approximately 5%–20% of AoC patients (8, 29).

Surgery is typically performed urgently once the diagnosis is confirmed. In premature or very low-birth-weight neonates, weight gain measures may sometimes be considered as palliative strategy (30, 31). However, successful primary surgical repair has been achieved in infants weighing over 1,000 g (32, 33), despite a higher rate of mid-term restenosis. Conversely, delayed diagnosis and/or repair in adulthood is associated with increased mortality (25). In standard settings, mortality and morbidity rates are low, with a 0.54% 30-day mortality (34).

Complications, including left recurrent laryngeal nerve injury, bronchial compression, early re-coarctation, and paradoxical hypertension, occur in approximately 5% of patients. Older age at repair (>20 years) and preoperative hypertension are associated with decreased survival rates (10). Patients younger than 9 years at the time of repair showed significantly lower rates of hypertension at 5–15 years of follow-up. Additionally, younger age at repair and end-to-end anastomosis correction are linked to fewer reintervention on the descending aorta.

The first balloon angioplasty for AoC was performed in 1982, by J. Lock (35). BA effectively reduces the pressure gradient in the short- to mid-term follow up. In cases of native AoC, it may be considered for extremely low-birth-weight infants or patients in cardiogenic shock as a bridge to surgery (36, 37) (Figure 2). However, several studies have indicated a higher risk of aneurysm formation and restenosis with isolated BA compared to surgery (4). Therefore, surgery remains the favored treatment for infants, while BA is often the first choice for managing recurrent AoC after surgical repair.

Both the AHA/ACC and ESC Guidelines recommend percutaneous stent implantation as the first-line treatment for adolescents and adults with AoC (4, 38, 39) (Figure 3). Several studies have demonstrated the high effectiveness of stenting, with lower morbidity and mortality rate compared to surgery. Unlike balloon angioplasty, stenting carries a minimal risk of aortic aneurysm and dissection (4, 40, 41).

In patients weighing between 15 and 40 kg, treatment strategies remain debated (12, 42, 43). While no definitive guidelines exist for children, stenting may be considered if the intended diameter is suitable for adult size or if the stent can be re-dilated to accommodate growth. The Cheatham-Platinum (CP) stent is the most commonly used device, although others, such as Palmaz Genesis and Andrastent (size L or XL), can also be useful, albeit with a risk of stent fracture (44, 45). Covered stents (e.g., covered CP stent, BeGraft stent, etc.) are particularly valuable in challenging cases, such as tight AoC, anatomies complicated by pseudoaneurysms, residual PDA shunts, aortic wall lesions, or aberrant vessel drainage (42).

Long-term outcomes with stents are generally excellent (7). However, late stent re-dilatation is often required when the initial procedure is performed before the age of 8, at a weight of less than 30 kg, or with a balloon diameter of less than 14 mm.

Paradoxical hypertension is often associated with AoC repair. The pathogenesis has yet to be determined, but it may be related to anatomical changes in the aorta and increased sympathetic nervous system activity: elevated plasma renin (49) and norepinephrine levels have been observed (50). This increase in norepinephrine is hypothesized to result from baroreceptor adaptation. After surgery or stent implantation, the pressure in the proximal aorta decreases, causing baroreceptors to reduce their inhibitory influence on the bulbar vasomotor centers. These centers then increase sympathetic nerve activity to compensate for the lowered proximal blood pressure, leading to increased norepinephrine release (50).

Post-surgical pain can also exacerbate hypertension, so adequate analgesic treatment is critical to mitigate this risk. Early management of postoperative hypertension is essential to reduce the risk of stroke, hemorrhage, and end-organ dysfunction.

Chronic hypertension is present in 20%–70% of AoC patients (2, 51), with its prevalence influenced by several factors. As expected, age is the most significant determinant. Studies have shown that the age at repair is the strongest predictor of long-term hypertension, independent of anatomical normalization (52, 53). This point might be due to several factors. First, early correction of AoC may limit exposure to hypertension and vascular wall stress (20, 54). Second, an effective surgical repair may prevent or avoid aortic arch hypoplasia. When surgical correction is performed above 15–20 kg, it becomes increasingly difficult to fully isolate the aortic arch, and the extent of surgical resection is larger, leading to significant stretching of the aortic segments (20). Similarly, percutaneous treatment of native AoC typically involves placing a stent distal to left subclavian artery, resulting in a stiffer, less elastic segment (21).

AoC patients have been shown to exhibit increased arterial stiffness and impaired flow-mediated arterial dilatation, suggesting a generalized impairment of large vessel function that coexists with AoC (54, 55). This impairment is more pronounced in patients with bicuspid aortic valve (56).

Pediatric obesity is also a known risk factor for hypertension (4), and its association with AoC leads to higher blood pressure and an increased risk of left ventricular hypertrophy in adolescents and young adults (57). On the other hand, different surgical techniques do not appear to significantly influence long-term blood pressure outcomes (58, 59).

Finally, residual aortic coarctation, palliative surgical strategies by using extra-anatomic conduits, coarctation repair by patch, complex aortic arch anatomies, and association to complex congenital heart diseases are additional risk factors for chronic hypertension (8, 29, 48, 60).

Despite the most effective surgical or interventional treatment, hypertension remains more common in AoC patients. In young patients with repaired AoC, masked hypertension (MH) may develop early and is sometimes associated with abnormal left ventricular structural and functional changes. These patients may have increased LV mass despite normal office blood pressure readings. In such cases, 24 h ambulatory blood pressure monitoring (ABPM) can help unmask this condition (48). The earliest sign of MH in ABPM is a non-dipper profile, characterized by the absence of a normal nocturnal decline in systolic and diastolic blood pressure. Eventually, daytime hypertension may also develop. Early diagnosis of masked hypertension enables prompt treatment: once residual AoC is excluded, treatment should be considered (see above) to prevent left ventricular systolic and diastolic dysfunction. Untreated hypertension is, in fact, a major determinant of long-term morbidity and mortality in these patients.

In AoC patients, hypertension can be exercise-induced. Blood pressure may increase during sport or physical activity, with the magnitude depending on the kind and intensity of exercise. Aerobic sports, such as cycling, running, and swimming, typically cause mild increase in blood pressure. In contrast, isometric and anaerobic sports (e.g., diving, weightlifting, shot put, etc) can lead to significant rises in both systolic and diastolic blood pressure. Finally, several sports, such as artistic and rhythmic gymnastics, volleyball, water polo and basketball may involve both types of exercise.

In clinical practice, exercise-induced hypertension is assessed using cycle ergometer or treadmill tests. While standard cut-off points exist for defining arterial hypertension in adults, well-defined prognostic standards for pediatric populations are still lacking. Specifically, in children, ranges vary based on several parameters, including sex, weight, and age (61). A study by Luitingh et al. demonstrated that patients with a peak exercise systolic blood pressure (SBP) exceeding 190 mmHg were consistently hypertensive ABPM and suggested that this threshold may be lower in younger population (62).

This condition occurs in up to one-third of the normotensive AoC patients (63, 64) and is considered an early indicator of hypertension, associated with a higher risk of developing chronic hypertension over the mid-term (65–67). As a result, exercise testing is routinely used to screen AoC patients from adolescence onwards. EIH patients are at increased risk for cardiovascular events and more pronounced LV remodeling (64) compared to normotensive patients. In adults with repaired AoC, EIH testing can also provide prognostic information and assess the efficacy of pharmacological treatment (64).

After correction, patients with AoC should undergo regular screening to assess their risk of developing hypertension. Follow-up should occur at least annually and include a clinical evaluation, ECG and echocardiography.

A comprehensive clinical evaluation for patients with AoC should include the assessment of radio-femoral delay, measurement of BMI, body surface area (BSA), and blood pressure in all four extremities at routine visit. This approach ensures identification of blood pressure discrepancies, a key diagnostic feature in this population. Blood pressure measurements should be taken in both arms and one or both legs, with leg measurements performed at least once during follow-up, particularly if a percutaneous procedure via the femoral artery was conducted. Z-scores for office blood pressure and ABPM are available based on sex, age and BSA. Overweight patients should be encouraged to lose weight and increase physical activity to enhance blood pressure control.

ECG is recommended for all patients with hypertension (68) and may be useful to identify patterns of myocardial hypertrophy (47). In adults, Sokolov's Index is frequently used to suspect left ventricular myocardial hypertrophy. In pediatric age, it cannot be used because of the high risk of false positive findings. Thus, in those patients, R wave in D-II higher than 20 mV is generally used as cut-off parameter for left ventricular hypertrophy.

Echocardiographic is recommended in patients with hypertension and ECG abnormalities (68). Assessment should include evaluation of systolic and diastolic function, the aortic flow pathway, and the presence of pressure gradients at the aortic valve, transverse arch and isthmus. Additionally, pulsed wave Doppler in the abdominal aorta can help assess blood flow propagation and elastic recoil (4, 69, 70). Echocardiography is a valuable tool for assessing aortic re-coarctation, commonly identifying a peak-to-peak gradient exceeding 20 mmHg, radiological evidence of narrowing with significant collateral flow, and left ventricular hypertrophy (70). However, the correlation between echo-derived isthmic gradient and invasive pressure gradient can be weak. Several factors can impact on echo velocities: the length of the stenosis, the associated aortic arch hypoplasia, the presence of hypertrophic collateral vessels bypassing the stenosis, impaired left ventricular function, the association with other congenital heart disease (in particular ventricular septal defect or patent ductus arteriosus), or sub-optimal alignment between probe and flow. Peak velocity (>2,5 m/s), mean gradient (>20 mmHg), V2-V1 peak gradient (>20 mmHg) and the presence of a diastolic flow tail were proposed as echo marker of AoC (71). On the other hand, the evidence of a demodulated abdominal aortic flow pattern is often the strongest predictor of clinically significant AoC. Anyhow, the utility of echocardiography is constrained by operator dependency, variability in acoustic windows, and limitations in visualizing extracardiac structures and collateral circulation. Consequently, advanced imaging modalities may be required for comprehensive evaluation in certain cases (4, 70).

Functional assessment of left ventricle includes evaluating wall thickness and calculating LV mass (70). Patients with AoC often develop LV pressure overload, leading to compensatory hypertrophy and, in some cases, myocardial fibrosis (70, 72). Despite successful repair, LV function frequently remains suboptimal, underscoring the importance of monitoring LV performance during long-term follow-up of CoA patients (72). Chronic pressure overload in CoA patients also significantly affects the left atrium (LA), leading to structural remodeling, fibrosis, and impaired function. LA strain imaging offers a valuable tool for evaluating both LA and LV performance throughout the cardiac cycle (73). Studies have shown evidence of LA dysfunction and LV diastolic dysfunction (LVDD) in CoA patients (74), however it is unknown whether these indices can be used for prognostication in this court of patients (75–77). A study showed that LA strain might show a potential clinical application, on the other side LV diastolic dysfunction is affected by too many factors (74).

In overweight and obese patients (78), LV mass should be indexed either by BSA or by height raised to the power of 2.7 (79). Most echocardiography software and reporting systems automatically calculate LV mass index based on BSA, which is generally sufficient. However, in obese patients, an increased BSA may lead to an underestimation of LV mass index, so using height may provide a more reliable measure.

Speckle tracking echocardiography is a sensitive tool for detecting subclinical sub-endocardial wall stress, which may be caused by residual AoC or newly onset of hypertension. Reduced global longitudinal strain values may warrant further anatomical evaluation and assessment of hypertensive status (80).

Even in patients with successful AoC repair and no hypertension, impaired longitudinal deformation properties have been observed (78). The degree of impairment correlates with age at repair and aortic stiffness (78).

Although early repair may delay hypertension onset, it cannot prevent the structural and functional abnormalities in the aorta that negatively affect myocardial deformation (78). In hypertensive patients with apparently normal systolic and diastolic function, applying the strain-time index (STI), can reveal preclinical LV systolic dysfunction (81, 82).

ABPM is a useful, non-invasive, and well-tolerated tool for diagnosing masked hypertension (83). Typically, the device records 50–70 blood pressure measurements, providing mean values and standard deviation for 24 h, daytime and nighttime periods. The report also lists the number of values outside the normal range for systolic and diastolic pressures. Standard settings apply to adult patients. Thus, before starting with data analysis, cut-off values should be tailored according to age, sex and BSA percentiles. Normally, mean values should remain below the upper limit identified, with less than 20% of readings above the threshold. At night, blood pressure should decrease by at least 10% (84). The absence of this nocturnal reduction is termed a “non-dipper profile” (85). It is important to note that the device's default nighttime settings should be adjusted based on the patient's sleep diary. ABPM is also valuable for monitoring the effectiveness of hypertension treatment, allowing clinicians to adjust doses and timings accordingly (84, 86).

Exercise testing is especially useful for identifying exercise-induced hypertension (64, 65). As mentioned above, BP should be measured in the right arm. An abnormal exercise BP profile may be due to several factors, such as mild or masked residual AoC, loss in aortic elasticity, idiopathic reasons. A bicuspid aortic valve can also increase the risk of idiopathic hypertension. Additionally, aortic valve stenosis may obscure or generate Doppler artifacts, making it difficult to assess isthmic flow and gradients. To overcome these limitations, an echocardiographic stress monitoring of the aortic arch may help clarify the diagnosis in these cases. Mild to moderate AoC can present with phasic isthmic flow and preserved abdominal aorta pulsed wave shape. With increased cardiac output, the Doppler profile might change. Aortic stenosis typically results in a systolic-only flow, whereas residual AoC may show a diastolic flow tail in both the arch and the abdominal aorta. Patients with moderate residual AoC and exercise-induced hypertension or aortic valve regurgitation may benefit from treatment of the residual lesion. A recent study has shown that exercise blood pressure may provide prognostic information and assess antihypertensive therapy efficacy in adults with repaired CoA (64, 66, 67).

Anatomic assessment of the aortic arch involves either CT scan or angio-CMR. CT scan with angiographic sequences provides detailed information about the aorta, supra-aortic vessels, and thoracic collaterals (Figure 4). It is the gold standard for detecting pseudoaneurysms, intimal tears and dissections (87). When performed with ECG gating and end-systolic acquisitions, CT can also aid in procedural planning (88, 89). However, the use of iodine contrast and radiation exposure limits the repeatability of this exam.

Angio-CMR provides high-quality images of the aorta, comparable to those of a CT scan in both native and surgically treated AoC. If limited to black-blood acquisitions, contrast media can be avoided. However, gadolinium contrast enhances anatomical details and provides important information about gradients (88) and abdominal blood flow. Like echocardiography, systolic peak and diastolic flow tails are the key indicators of residual AoC. While angio-CMR is more time-consuming, operator-dependent, more expensive, and may require sedation in infants and children (70), it is more repeatable than CT, especially when performed without contrast. Unfortunately, its diagnostic accuracy worsen significantly when metallic device are present in the aorta (e.g., aortic stents, ductus arteriosus devices, etc) or nearby (e.g., mechanical valves, pacemaker, orthopedic prostheses, etc). In these cases, a CT scan is preferred.

Patients with AoC are at risk of cerebral artery anomalies, particularly vascular aneurysms (13, 14). In these patients, hypertension can lead to aneurysm rupture and consequent cerebral hemorrhage. Therefore, imaging of cerebral arterial tree (via angio-CT or angio-CMR) might be proposed at diagnosis in AoC patients diagnosed out of neonatal age.

Hypertension is a strong determinant of carotid intima-media thickness (CIMT), which is a predictor of atherosclerosis. Consequently, the effect of statins on patients with repaired AoC has been studied. In the study of Luijendijk P et al. (90) it was confirmed that hypertensive patients with repaired AoC exhibited significant CIMT progression. However, in this study, atorvastatin treatment was not effective in reducing these complications, despite a marked reduction in serum total cholesterol and LDL levels. Conversely, the study of Brili et al. (91) demonstrated significant improvements in endothelial function and decreased circulating levels of pro-inflammatory cytokines in patients with repaired AoC.

During long-term follow-up after AoC repair, cardiovascular risk increases due to an endothelial dysfunction and elevated expression of inflammatory proteins. The effect of ramipril's (an ACE inhibitor) was studied in these patient group and was shown to be effective in improving endothelial function and reducing the expression of proatherogenic inflammatory cytokines and adhesions molecules (92).

Intravenous drugs are usually preferred in the intensive care unit. Hypertension is quite common after surgery, potentially due to neuro-autonomic changes and the pain associated with the procedure. Achieving adequate BP control is essential to reduce the risk of cerebral bleeding and suture dehiscence. Additionally, lowering BP reduces afterload, which can be beneficial in patients with preoperative left ventricular dysfunction. Thus, antihypertensive might also have an inotrope-sparing effect.

Sodium nitroprusside (SNP) is typically the first choice for treating hypertension following aortic coarctation repair (93). Its effect results from its breakdown into nitric oxide (NO), which exerts a potent vasodilatory effect on arterioles. The action is focused on arterial vessels, with no impact on inotropy. Due to its very short half-life, SNP can be easily managed by adjusting the dose. However, SNP promotes the development of free radicals, so its use beyond 48 h might result toxic for the patient.

Esmolol is a selective beta-1 receptor blocker with rapid onset (within seconds), rapid peak effect, and very short duration of action, degraded by esterases in the cytosol of red blood cells. These characteristics offer several advantages over propranolol in the treatment of paradoxical hypertension after AoC repair (94). In a study comparing esmolol to sodium nitroprusside, esmolol was found wo be effective in treating paradoxical hypertension, either as monotherapy or in combination (95), with an excellent safety profile (94). Like SNP, Esmolol doses can be easily adjusted to tailor the effect for the patient. However, like other B-1 blockers, Esmolol impacts cardiac function by reducing heart rate, inotropy, and oxygen consumption. Therefore, its use should be approached cautiously in patients with cardiogenic shock.

Labetalol is a non-selective, competitive beta-adrenergic (B1 and B2) blocker and a selective alpha1-adrenergic antagonist, with a rapid onset and peak effect, and a half-life of 3–5 h. Unlike Esmolol, Labetalol has a longer duration of action, making dose adjustments more difficult. Retrospective study have indicated that it is a safe single-agent therapy for treating hypertension post-coarctectomy, with the added advantage of easy transition from intravenous to oral administration (96). However, this therapy has a negative association with ductus-dependent circulation (96).

Dexmedetomidine is an intravenous analgo-sedative used both intraoperatively and postoperatively. It is a highly selective alpha-2 agonist, a drug that exerts multiple effects. Dexmedetomidine reduces central sympathetic output, inhibits the release of epinephrine, norepinephrine and renin release, thereby lowering arterial blood pressure (97, 98). In conclusion, its ancillary effects on the cardiovascular system, combined with its primary sedative and analgesic effects, make this drug ideal for postoperative care of patients with AoC in intensive care unit (97, 99). A recent study demonstrated that dexmedetomidine is safe and that it reduces the incidence and severity of paradoxical hypertension, as well as the need for antihypertensive medications in patients undergoing aortic coarctation repair (100).

After the first 48 h, patients can often be weaned off intravenous antihypertensive drugs. Once discharged from intensive care unit, the patient may either remain off therapy or transition to oral therapy. The choice is based on the pre-surgical clinical condition, BP values, and patient's age. Neonates with a pre-natal diagnosis of AoC can be treated promptly with adequate LV function. In these patients, mid-term oral treatment is usually unnecessary. Patients without a prenatal diagnosis often present for surgery in poor clinical condition, with low cardiac output, biventricular dysfunction, metabolic acidosis, and oligo-anuria. In these cases, mid-term oral therapy should be considered to promote the left ventricle reverse remodeling. In adult patients, hypertension may persist for several weeks following AoC correction; therefore, mid-term therapy is also recommended for these patients.

In pediatric patients (including both children and adolescents), there is currently no general consensus on the management of arterial hypertension. In the normal population the most recent guidelines agree on initiating the treatment with non-pharmacological interventions, focusing on improving adherence to a healthy lifestyle, including reducing the intake of salt-rich foods (101).

However, this approach is not recommended in patients with AoC, as hypertension in these cases is caused by a structural issue. In this cohort of patients, pharmacological therapy is indicated.

The range of drugs available for chronic hypertension is extensive. However, the options available for pediatric patients are much more limited. Similarly, data on hypertension in CHD patients, including AoC, is restricted to only a few drug classes.

Beta-blockers (Table 1) are currently considered the first-line therapy for AoC. Numerous studies have demonstrated the safety and efficacy profile of beta-blockers in patients with AoC patients (94, 96, 102). The utility of beta-blockers is not limited to hypertension management; several studies suggest their use in preventing aortic dilatation and ascending aorta aneurisms, particularly when AoC is associated to bicuspid aortic valve. Beta-blocker are classically categorized into β1-selective and non-selective.

First-generation beta-blockers, such as propranolol, nadolol, timolol, sotalol and pindolol, block both β1 and β2 receptors. Consequently, this group affects cardiomyocytes, smooth muscle cells in blood vessels, and the lungs, with bronchoconstriction as a potential side effect. Thus, these drugs are no longer used to treat hypertension.

Second-generation beta-blockers, including metoprolol, acebutolol, bisoprolol, esmolol, betaxolol, and acebutolol, are β1 selective. This group has been extensively studied for heart failure and heart rate control. They have significantly lower impact on bronchoconstriction and peripheral vasodilatation.

Pindolol, penbutolol, and acebutolol differ from other beta-blockers due to their intrinsic sympathomimetic activity (ISA), which can increase blood pressure and heart rate. This class of Beta-Blockers has a smaller effect on reducing resting cardiac output and resting heart rate compared with other classes.

Third-generation Beta-blockers include labetalol and carvedilol, which block both β- and α1-adrenergic receptors, creating a synergistic effect that induces vasodilation and to reduces blood pressure.

Beta-blockers can also be classified as lipophilic and hydrophilic. The clinical significance of this classification relates to the volume of distribution and the drug's effect on the brain. Lipophilic Beta-blockers can cross the blood-brain barrier and exert additional effects on the central nervous system, therefore, the use of this class of drugs should depend on the risk of adding depressive symptoms.

Propranolol was the first beta-blocker available on the market. It was effectively used in the perioperative period for coarctation repair, where it was shown to significantly reduce systolic and diastolic blood pressure as well as plasma renin activity (103). Its role has been evaluated as a prophylactic therapy for the prevention of paradoxical hypertension after AoC repair (103, 104). Propranolol has a relatively short half-life, requiring administration 3–4 times per day.

Atenolol is a non-selective beta-blocker that can be administrated once or twice per day. Over the past two decades, several studies have demonstrate that Atenolol may be considered a first-line treatment for AoC.

The most common side effects of BB include bradycardia, bronchospasm, asthma, Raynaud's disease, and hypoglycemia in diabetics.

Calcium channel blockers (CCBs) (Table 2) play a pivotal role in the management of AoC. This class of drugs is divided in two categories: dihydropyridines and non-dihydropyridines. The first group acts selectively on peripheral arteries, causing arteriolar vasodilation and an effective reduction in blood pressure. Non-dihydropyridines also act on cardiomyocytes, primarily suppressing sympathetic stimuli, thereby decreasing heart rate, blood pressure, inotropy and dromotropy.

CCBs are typically used as second-line treatment in pediatric patients due to the risk of hypotension. They are often considered when BBs are insufficient to achieve adequate blood pressure control. Dihydropyridine CCBs are commonly used to treat postoperative hypertension in adults are nifedipine, amlodipine and nicardipine are the almost known molecule. They have a rapid onset and peak effect, increase cardiac output by enhancing venous return, and reduce oxygen consumption by lowering afterload (105). The half-life of CCBs is usually short or very short, making them particularly effective in case of hypertensive crises. However, for chronic use, controlled-released formulations are needed to stabilize plasma concentration and reduce the frequency of daily administration.

The most common side effects of CCBs include flushing, headache, peripheral edema, dizziness, and paradoxical hypotension.

ACE-I (Table 3) are a common first-line treatment for hypertension at any age. They induce arteriolar vasodilatation. Due to their large extensive use in pediatric and neonatal heart failure, wide therapeutic range and low risk of adverse effects, ACE-Is are increasingly replacing BB as first-line treatment for hypertension. Several ACE-I molecules are available, differing in onset and half-life. Captopril was the first ACE-I introduced, with a rapid onset and short half-life. Requiring administration three of four times daily for complete coverage. Enalapril has a slightly longer half-life and is administrated twice daily, while Ramipril, Lisinopril, and Perindopril allow for once-daily administration. Unlike BB, ACE-Is mainly differ in terms of half-life and time to peak dose.

The most common side effects of ACE-Is include renal dysfunction, hyperkalemia, and cough. ACE-Is are contraindicated during pregnancy.

Angiotensin receptor blockers (ARBs) (Table 4) act by inhibiting the effects of angiotensin II at its receptor sites, thereby preventing its vasoconstrictive action and reducing sodium and water retention through modulation of renal and vascular pathways. ARBs specifically block AT1 receptors, which are found in the heart, blood vessels and kidneys. Consequently, ARBs are used to treat hypertension, heart failure and chronic kidney disease. Additionally, they can be used to prevent aortic wall dilatation in collagenopathies (e.g., Marfan Syndrome). Losartan, Valsartan, Irbesartan, Olmesartan, and Candesartan are the most commonly used ARBs. They may be considered first-line drugs in adults due to the high response rate, low incidence of adverse effects, and long-acting nature, which typically allows for once-daily dosing. In pediatric patients, ARBs are considered when ACE-Is are poorly tolerated (e.g., due to cough). Side effects include hyperkalemia, altered taste, and skin rash. Similar to ACE-Is, ARBs are contraindicated during pregnancy.