Sobhy Mohamed, Eletriby Adel, Ragy Hany, Kandil Hossam, Saleh Mohamed Ayman, Farag Nabil, Guindy Ramez, Bendary Ahmed, Nayel Ahmed Mohamed Elmahmoudy, Shawky Ahmed, Khairy Ayman, Mortada Ayman, Zarif Bassem, Badran Haitham, Khorshid Hazem, Mahmoud Kareem, Said Karim, Leon Khaled, Abdelsabour Mahmoud, Tawfik Mazen, Abdelmegid Mohamed Aboel-Kassem F, Koriem Mohamed, Loutfi Mohamed, Wadie Moheb, Elnoamany Mohamed, Sadaka Mohamed, Seleem Mohamed, Zahran Mohamed, Amin Osama A, Elkaffas Sameh, Ayad Sherif, Kilany Wael El, Ammar Walid, Elawady Waleed, Elhammady Walid, Abdelhady Yasser
Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
Cardiovascular Research, Education and Prevention (CVREP) Foundation, Alexandria, Egypt.
Cardiol Ther. 2024 Dec;13(4):707-736. doi: 10.1007/s40119-024-00381-6. Epub 2024 Oct 25.
The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in regulating blood pressure (BP), with dysregulation of RAAS resulting in hypertension and potentially heart failure (HF), myocardial infarction (MI), cardio-renal syndrome, and stroke. RAAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), have advantages beyond BP control. However, differences between these two drug classes need to be considered when choosing a therapy for preventing cardiovascular events.
A panel of 36 Egyptian cardiologists developed consensus statements on RAAS inhibitors for primary and secondary prevention of cardiovascular outcomes and stroke, using a modified three-step Delphi process.
The consensus statements highlight the importance of effective BP control and the role of RAAS blockade for prevention and management of various cardiovascular diseases. ACEis and ARBs differ in their mode of action and, thus, clinical effects. On the basis of available evidence, the consensus group recommended the following: ACEis should be considered as first choice (in preference to ARBs) to reduce the risk of MI, for primary prevention of HF, and for secondary prevention of stroke. ACEis and ARBs show equivalent efficacy for the primary prevention of stroke. Evidence also favors the preferential use of ACEis in patients with type 2 diabetes, for BP control, for the primary prevention of diabetic kidney disease, and to reduce the risk of major cardiovascular and renal outcomes. Treatment with an ACEi should be started within 24 h of ST segment elevation MI (and continued long term) in patients with HF, left ventricular systolic dysfunction, and/or diabetes. Angiotensin receptor/neprilysin inhibitors (ARNIs) are the first choice for patients with HF and reduced ejection fraction, with ACEis being the second choice in this group. ARBs are indicated as alternatives in patients who cannot tolerate ACEis. ACEis may be associated with cough development, but the incidence tends to be overestimated, and the risk can be reduced by use of a lipophilic ACEi or combining the ACEi with a calcium channel blocker.
RAAS blockade is an essential component of hypertension therapy; however, the protective effects provided by ACEis are superior to those of ARBs. Therefore, an ACEi is indicated in almost all cases, unless not tolerated.
肾素-血管紧张素-醛固酮系统（RAAS）在调节血压（BP）方面起着关键作用，RAAS失调会导致高血压，并可能引发心力衰竭（HF）、心肌梗死（MI）、心肾综合征和中风。RAAS抑制剂，如血管紧张素转换酶抑制剂（ACEI）和血管紧张素受体阻滞剂（ARB），其益处不仅限于控制血压。然而，在选择预防心血管事件的治疗方法时，需要考虑这两类药物之间的差异。
由36名埃及心脏病专家组成的小组，采用改良的三步德尔菲法，就RAAS抑制剂用于心血管结局和中风的一级和二级预防制定了共识声明。
共识声明强调了有效控制血压的重要性以及RAAS阻断在预防和管理各种心血管疾病中的作用。ACEI和ARB的作用方式不同，因此临床效果也不同。根据现有证据，共识小组建议如下：应将ACEI视为降低MI风险、HF一级预防和中风二级预防的首选（优先于ARB）。ACEI和ARB在中风一级预防方面显示出同等疗效。证据还支持在2型糖尿病患者中优先使用ACEI来控制血压、一级预防糖尿病肾病以及降低主要心血管和肾脏结局的风险。对于HF、左心室收缩功能障碍和/或糖尿病患者，应在ST段抬高型MI发生后24小时内开始使用ACEI治疗（并长期持续）。血管紧张素受体/中性肽链内切酶抑制剂（ARNI）是射血分数降低的HF患者的首选，ACEI是该组患者的次选。ARB适用于不能耐受ACEI的患者。ACEI可能与咳嗽的发生有关，但发生率往往被高估，使用亲脂性ACEI或将ACEI与钙通道阻滞剂联合使用可降低风险。
RAAS阻断是高血压治疗的重要组成部分；然而，ACEI提供的保护作用优于ARB。因此，除非不耐受，几乎在所有情况下都应使用ACEI。
