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European Heart Journal Advance Access originally published online on August 16, 2005
European Heart Journal 2005 26(22):2361-2367; doi:10.1093/eurheartj/ehi454
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Addition of an angiotensin receptor blocker to full-dose ACE-inhibition: controversial or common sense?

Ruud M.A. van de Wal1,*, Dirk J. van Veldhuisen2, Wiek H. van Gilst3 and Adriaan A. Voors2

1Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, PO Box 2500, 3435 CM Nieuwegein, The Netherlands
2Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
3Department of Clinical Pharmacology, University Medical Center Groningen, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands

Received 18 March 2005; revised 4 July 2005; accepted 13 July 2005; online publish-ahead-of-print 16 August 2005.

* Corresponding author. Tel: +31 30 6093269; fax: +31 30 6034420. E-mail address: r.wal{at}antonius.net

Abstract

Both angiotensin-converting enzyme (ACE)-inhibitors and angiotensin receptor blockers (ARBs) interfere with the activity of the renin–angiotensin system (RAS) in a different way. Theoretically, one might expect beneficial effects when they are used in combination, as a more complete suppression of the RAS can be achieved. But can this additional effect still be seen in patients on full-dose ACE-inhibition? Several controlled trials demonstrated that combination therapy can have additional benefits in hypertensive patients, in chronic heart failure patients, and in both diabetic and non-diabetic nephropathy patients. However, the clinical benefit was not always as pronounced as expected and not every patient will benefit from dual blockade of the RAS. There is some evidence of a less pronounced effect of combination therapy when a full dose of the ACE-inhibitor is given. However, it is well known that ACE-inhibitors cannot completely suppress the formation of angiotensin II, in particular, when the RAS is activated. Indeed, clinical trials indicated that add-on therapy with an ARB was especially of use when the RAS remained activated despite full-dose ACE-inhibitor treatment. In summary, combination of a full-dose ACE-inhibitor and an ARB can be a rational choice in selected patients.

Key Words: Renin angiotensin system • Cardiovascular disease • Ace-inhibitor • Angiotensin receptor blockade • Dual blockade


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