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Optimal renin–angiotensin system blockade—wishful thinking?

Nature Reviews Cardiology volume 10, page 486 (2013)Cite this article

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We read with interest the News & Views by Jürg Nussberger and Jürgen Bohlender (Optimal blockade of the renin–angiotensin–aldosterone system. Nat. Rev. Cardiol. 10, 183–184 (2013)1 highlighting the role of dual renin–angiotensin system (RAS) blockers in the management of cardiovascular diseases. The News & Views article was written in response to our meta-analysis comparing the efficacy and safety outcomes of RAS blockade using monotherapy or combination therapy.2 We agree with Nussberger and Bohlender that optimal, rather than complete, RAS blockade should be the goal of therapy regardless of whether RAS blockade is given for hypertension, heart failure, coronary heart disease, or other indications.

Nussberger and Bohlender define optimal RAS blockade as the maximal blockade achieved without causing hypotension, hyperkalaemia, or renal dysfunction. Our meta-analysis, which included data for >60,000 patients, documented no incremental benefit of dual RAS-blocker therapy compared with single RAS blockade.2 To the contrary, we actually observed harm in the form of hypotension, hyperkalaemia, renal dysfunction, or a combination of these conditions in some patients. This finding simply indicates that dual RAS blockade does not fulfill the Nussberger and Bohlender criteria of optimal RAS blockade. Thus, by definition, dual RAS blockade cannot be considered 'optimal' RAS blockade.

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References

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Authors and Affiliations

  1. Division of Cardiology, St Luke's–Roosevelt Hospital, Columbia University College of Physicians and Surgeons, 1000 10th Avenue, Suite 3B30, New York, 10019, NY, USA

    Harikrishna Makani & Franz H. Messerli

  2. The Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, 10016, NY, USA

    Sripal Bangalore

Authors
  1. Harikrishna Makani
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  2. Sripal Bangalore
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  3. Franz H. Messerli
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Correspondence to Franz H. Messerli.

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Competing interests

S. Bangalore declares that he has been on advisory boards for the following companies: BoehringerIngelheim, Daiichi Sankyo, and Pfizer. F. H. Messerli declares that he has been an ad hoc consultant/speaker for the following companies: Abbott, Bayer, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Servier, and Takeda. H. Makani declares no competing interests.

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Makani, H., Bangalore, S. & Messerli, F. Optimal renin–angiotensin system blockade—wishful thinking?. Nat Rev Cardiol 10, 486 (2013). https://doi.org/10.1038/nrcardio.2013.28-c1

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