ARBs and ACEis together in the treatment of hypertension and its complications? current practical recommendations

IMPORTANCE OF THE FIELD: Arterial hypertension is highly prevalent in the general population. Its contribution to the development and evolution of cardiovascular and renal disease is well recognized. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) have demonstrated favorable effects on cardiovascular and renal prognosis; however, some limitations have been described, for example angiotensin and aldosterone breakthrough. AREAS COVERED IN THIS REVIEW: This article describes several therapeutical strategies that can be administered with an ACEi or ARB, such as the direct renin inhibitors or the aldosterone receptor antagonists. WHAT THE READER WILL GAIN: The addition of an ACEi to an ARB or vice versa was initially considered as a way of obtaining a stronger suppression of the renin-angiotensin-aldosterone system (RAAS), but recent evidence has shown that the combination of the two classes of drugs does not seem to afford the expected increase in benefit. TAKE HOME MESSAGE: RAAS suppression with monotherapy is associated with beneficial cardiovascular effects, but has several limitations. Direct renin inhibitors and aldosterone receptor antagonists will increase the benefits of dual blockade. We need randomized trial data supporting reduction of cardiovascular events with an adequate safety profile using combination therapies.