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European Heart Journal Advance Access published online on August 16, 2005
European Heart Journal, doi:10.1093/eurheartj/ehi454
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European Heart Journal © The European Society of Cardiology 2005; all rights reserved
Received March 18, 2005
Revised July 4, 2005
Accepted July 13, 2005

Current opinion

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

Ruud M.A. van de Wal 1*, Dirk J. van Veldhuisen 2, Wiek H. van Gilst 3, and Adriaan A. Voors 2

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

* To whom correspondence should be addressed.
Ruud M.A. van de Wal, E-mail: 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.

Keywords: Renin angiotensin system; Cardiovascular disease; Ace-inhibitor; Angioten receptor; Dual blockade.
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
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