Kolasinska-Malkowska Katarzyna, Filipiak Krzysztof J, Gwizdala Adrian, Tykarski Andrzej
Katedra i Klinika Hipertensjologii, Angiologii i Chorób Wewnetrznych, Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu, Poland.
Expert Rev Cardiovasc Ther. 2008 Jun;6(5):759-71. doi: 10.1586/14779072.6.5.759.
The renin-angiotensin-aldosterone system (RAAS) plays a crucial role in blood pressure regulation and hypertension-related complications. Angiotensin-converting enzyme inhibitors (ACEIs) were the first to be used to block the RAAS and now have many compelling indications in the treatment of hypertension and its cardiovascular and renal complications. Angiotensin II receptor blockers (ARBs), introduced 20 years later, have been shown to be equally as effective as antihypertensive treatment and are also associated with a lower number of side effects. Furthermore, in clinical trials ARBs and ACEIs were associated with comparable benefits for their most typical indications. This was confirmed in the 2007 New European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines for the management of hypertension by comparable specific recommendations for ARB and ACEI treatment. There is sufficient theoretical background and, in some cases, also clinical evidence that combination therapy with ACEIs and ARBs may be more beneficial than monotherapy with either of the groups alone, both in uncomplicated hypertension and with concomitant heart failure or renal dysfunction. However, the combination of ACEI and ARB was not recommended in the ESH/ESC 2007 Guidelines. This may change after the publication of the Ongoing Telmisartan Alone and in Combination with Ramipril Global End point Trial (ONTARGET) study, the preliminary results of which have just been presented. In heart failure, recent studies have shown that the combination of ACEI and ARB decreases cardiovascular mortality and the number of hospitalizations due to aggravation of heart failure. These results have been reflected in the newest ESC guidelines of the heart failure treatment. Nephroprotective properties of the combination of ACEs and ARBs have been proved both in studies on nondiabetic and diabetic nephropathy. The potential benefits, indications in prespecified groups of patients, the most recent data from clinical trials and latest research regarding dual blockade of RAAS will be reviewed in this article.
肾素-血管紧张素-醛固酮系统（RAAS）在血压调节及高血压相关并发症中起关键作用。血管紧张素转换酶抑制剂（ACEI）是最早用于阻断RAAS的药物，目前在高血压及其心血管和肾脏并发症的治疗中有诸多令人信服的适应证。20年后引入的血管紧张素II受体阻滞剂（ARB）已被证明在抗高血压治疗方面同样有效，且副作用数量也较少。此外，在临床试验中，ARB和ACEI在其最典型适应证方面具有相当的益处。2007年欧洲高血压学会/欧洲心脏病学会（ESH/ESC）高血压管理指南通过对ARB和ACEI治疗的类似具体建议证实了这一点。有充分的理论背景，在某些情况下也有临床证据表明，在单纯性高血压以及伴有心力衰竭或肾功能不全的情况下，ACEI与ARB联合治疗可能比单独使用其中任何一组进行单一治疗更有益。然而，ESH/ESC 2007指南不推荐ACEI与ARB联合使用。在正在进行的替米沙坦单药及与雷米普利联合使用的全球终点试验（ONTARGET）研究结果公布后，情况可能会有所改变，该研究的初步结果刚刚公布。在心力衰竭方面，最近的研究表明，ACEI与ARB联合使用可降低心血管死亡率以及因心力衰竭加重导致的住院次数。这些结果已反映在最新的ESC心力衰竭治疗指南中。ACEI与ARB联合使用在非糖尿病和糖尿病肾病研究中均已证明具有肾脏保护作用。本文将综述RAAS双重阻断的潜在益处、特定患者群体的适应证、临床试验的最新数据以及最新研究情况。
