ARBs and ACEis together in the treatment of hypertension and its complications? current practical recommendations

Abstract

RAAS suppression with monotherapy is associated with beneficial cardiovascular effects, but has several limitations. Direct renin inhibitors and aldosterone receptor antagonists will increase the benefits of dual blockade. We need randomized trial data supporting reduction of cardiovascular events with an adequate safety profile using combination therapies.

Efficacy and safety of valsartan in hypertensive children 6 months to 5 years of age

“…Inhibitors of the renin-angiotensin system (RAS) such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have been extensively studied in adult populations and have demonstrated sustained BP-lowering efficacy in addition to being widely studied in a number of cardiovascular morbidity and mortality studies [9][10][11][12]. The efficacy and safety of these agents have been more recently characterized in older children, [8,13] and they may become an attractive therapeutic consideration in younger hypertensive children owing to their added antiproteinuric effects when proteinuria is present [7,8].…”

Cardiorenal disease development under chronic renin–angiotensin–aldosterone system suppression

“…With regards to patients with heart failure, combinations of ACEIs and ARBs have been shown to have cardiovascular benefits over single RAS blockade. 1,19 Addition of an aldosterone blocker to standard RAS inhibition has also improved all-cause mortality in the Randomized Aldactone Evaluation Study (RALES), Eplerenone Heart Failure Efficacy and Survival Study (EPHESUS) and Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS) study. [20][21][22] Such approaches of aggressive RAS blockade, however, should be balanced against the possibility that absence of albuminuria indicates another paradigm of kidney disease, i.e.…”

“…ischaemic nephropathy, and that aggressive RAAS inhibition can also be harmful in some cases. 19,23 The analysis of renal events in the ONTARGET study showed that dual RAAS blockade did not confer any benefit in terms of renal outcomes and significantly increased the risk of dialysis for acute renal failure. 10 Furthermore, the Aliskiren Trial In Type 2 diabetes Using cardio-renal Disease Endpoints (ALTITUDE), which was designed to compare the effects of combination treatment of aliskiren and ACEI or ARB versus ACE or ARB alone on cardiovascular and renal outcomes in patients with type 2 diabetes with macroalbuminuria or with eGFR 30-60 ml/min per 1.73 m 2 and microalbuminuria or history of cardiovascular events, was prematurely terminated following the recommendation of the data safety and monitoring committee.…”