Plasma Renin Measurement in the Management of Hypertension: The V and R Hypothesis

Cardiovascular Events in Hypertension Trials of Angiotensin‐Converting Enzyme Inhibitors

Angiotensin-converting enzyme inhibitors are widely-prescribed drugs for hypertension and are supported by clinical trials in which they reduce cardiovascular events. In the high-risk patients in the Heart Outcomes Prevention Evaluation, the Perindopril Protection Against Recurrent Stroke Study, and European Trial of Reduction of Cardiac Events With Perindopril in Stable Coronary Artery Disease, ramipril and perindopril showed impressive benefits. One reason trandolapril did somewhat less well in the Prevention of Events With Angiotensin-Converting Enzyme Inhibition trial may be that its patients were very well treated with other effective modalities. In the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial, lisinopril-treated patients had a slightly lower incidence of myocardial infarction, despite much poorer control of blood pressure, perhaps because a second-line diuretic was prohibited by protocol. Although angiotensin-converting enzyme inhibitors can cause cough and angioedema (more common among blacks), angiotensin receptor blockers are currently more expensive and have fewer outcome trials to support their use.

Your Drug, My Drug, or Our Drugs: How Aggressive Should We Be With Antihypertensive Therapy?

In the prevention of hypertensive complications, especially stroke and kidney disease, "lower is better" because for each decrease of 20 mm Hg systolic or 10 mm Hg diastolic pressure in the population, cardiovascular risk is halved. Ideally, the goal for each patient should be to reach the lowest blood pressure that is well tolerated, a value that may be well below the arbitrary threshold value of 140/90 mm Hg. For the majority of "uncomplicated hypertensives," the question of single-drug therapy is essentially moot, because more than one agent is almost always required to optimally control blood pressure. In individuals who already have heart or kidney disease, there are compelling indications for the use of drugs that block the renin-angiotensin system, but the large outcome studies that spawned these recommendations are themselves combination trials. Thus, in virtually all patients, more than one drug is indicated. The best combinations take advantage of long durations of action and complementary mechanisms of action of the component and are not only able to effectively lower blood pressure, but also to favorably affect the natural history of hypertensive complications. Regimens-including fixed-dose combination products-that combine a thiazide diuretic or calcium antagonist with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker are most efficient. In summary, why would an astute clinician (or informed patient) be satisfied with the relatively limited effects of any single class of antihypertensive agents when better overall protection is possible?

Angiotensin-converting enzyme inhibitor use in the year 2005

The angiotensin-converting enzyme (ACE) inhibitor drug class is one with considerable staying power. ACE inhibitors are not only well established antihypertensive agents but also are compounds that fairly regularly provide end-organ protection. Several of the ACE inhibitors are entangled in an active debate regarding class effect. Class effect for ACE inhibitors is a hopelessly confused term because its definition is not standardized and is subject to interpretation that in many cases is self-serving. For the most part, ACE inhibitor side effects are readily identifiable, and management strategies put in place can be logical and sequential. The future of this drug class remains bright. Other drug classes, such as angiotensin receptor blockers, have narrowed-but not entirely closed-the outcomes gap that exists between these two drug classes.