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Angiotensin-Converting Enzyme Inhibitors versus AT1 Receptor Antagonist in Cardiovascular and Renal Protection: The case for AT1 Receptor Antagonist

University of Colorado Health Sciences Center, Department of Medicine, Division of Renal Diseases and Hypertension, Denver, Colorado

Correspondence to Dr. Tomas Berl, University of Colorado Health Sciences Center, Department of Medicine, Division of Renal Diseases and Hypertension, 4200 East 9th Avenue, Box C-281, Denver, CO 80262. Phone: 303-315-7203; Fax: 303-315-4852; E-mail: Tomas.Berl{at}uchsc.edu

ABSTRACT. The development of pharmacologic agents that directly inhibit the angiotensin II receptor (angiotensin receptor blocker [ARB]) has provided clinicians with an alternative to the previously available angiotensin-converting enzyme inhibitors (ACEI) to downregulate the renin-angiotensin system. This review focuses on the available data that can guide the clinician to the use of these two classes of agents vis à vis their ability to provide cardiovascular (CV) and renal protection. Although the CV protective effect of ACEI in high-risk populations is widely appreciated, whether such an effect is entirely BP independent can be questioned. Most head-to-head comparisons between ACEI and ARB have yielded comparable CV protective effects, with ARB being associated with fewer adverse effects. Likewise, several—but not all—studies have demonstrated a CV protective effect of ACEI when compared with other active agents in patients with type 2 diabetes. One study demonstrated a similar protection with ARB when compared with a blocker. In terms of renal protection, there are ample data to support a role for both ACEI and ARB to prevent the progression from microalbuminuria to overt albuminuria in both type 1 and type 2 diabetes. However, when progression of renal disease is used as an end point, protection has been demonstrated with ACEI only for type 1 but not type 2 diabetes. In this latter group, only ARB have been shown to slow progression to ESRD.

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Copyright © 2008 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673