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What does the future hold? ACE inhibition, angiotensin II receptor blockade, and diabetic nephropathy.

The influence that ACE inhibition has had on the natural history of cardiovascular and renal disease is remarkable, exceeding the expectations of even the most optimistic adherents. With the development of AngII antagonists, the mechanism by which ACE inhibitors reduce tissue injury has become an important problem. If the ACE inhibitors had their useful action through non-angiotensin-dependent mechanisms such as reduced kinin degradation, then AngII antagonist will not prove as useful. Conversely, if the major influence of the ACE inhibitors reflected a reduction in AngII formation, then the AngII antagonists will show real promise not only in matching the influence of the ACE inhibitors, but perhaps exceeding their ability to influence natural history, because the AngII antagonists will block non-ACE pathway-dependent AngII generation.