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Addressing Gaps in Our Knowledge of the Angiotensin Receptor Blockers: Report of a Roundtable

Articles originating in the 1970s demonstrated the role of the renin-angiotensin system (RAS) in increasing blood pressure (BP) in a large proportion of patients with hypertension. This observation helped popularize the use of b-blockers for treating hypertension based on the ability of these agents to decrease renin release from the kidney. Later, angiotensin-converting enzyme (ACE) inhibitors and, more recently, angiotensin receptor blockers (ARBs), have provided powerful and effective means for interrupting the RAS. An even newer drug class, the direct renin inhibitors, is now available, although not yet as well studied as the ACE inhibitors or ARBs. Beyond their effectiveness in treating hypertension, ACE inhibitors and ARBs have by now established strong credentials for treating other conditions. These include heart failure, either chronic or following a myocardial infarction, patients at high cardiovascular (CV) risk, and diabetic and nondiabetic chronic kidney disease. It is noteworthy that these drug classes have been shown to have benefits comparable with other major drug classes in preventing mortality and morbidity when treating hypertension. Beyond their BP-lowering efficacy, the blockers of the RAS are well tolerated, although ACE inhibitors can cause chronic cough in a meaningful proportion of patients and may also provoke angioedema in a small number of individuals. ARBs appear to have tolerability profiles similar to placebo. It is not surprising, therefore, that ACE inhibitors and ARBs have become regarded as appropriate core therapies in hypertension and that most patients started on antihypertensive therapy will now receive one of these types of drugs. Still, there is more to be learned about these blockers of the RAS, particularly the ARBs.