Inhibitors of the renin angiotensin system: implications for the anaesthesiologist

Area of Science:

• Pharmacology
• Cardiovascular Medicine
• Nephrology

Background:

• Angiotensin-converting enzyme (ACE) inhibitors demonstrate significant long-term benefits in arterial hypertension, cardiac insufficiency, coronary artery disease, and renal diseases.
• Long-term ACE inhibitor treatment impacts cardiovascular responses to anesthesia and surgery.
• Emerging evidence suggests short-term renin-angiotensin system blockade may offer perioperative organ protection and improve circulatory status.

Purpose of the Study:

• To review the established and potential benefits of ACE inhibitors.
• To discuss alternative pathways in angiotensin II formation.
• To compare ACE inhibitors with angiotensin II receptor antagonists in clinical practice.

Main Methods:

• Literature review of studies on ACE inhibitors and the renin-angiotensin system.
• Analysis of the mechanisms of action of ACE inhibitors, including kinin accumulation.
• Comparison of ACE inhibitors with angiotensin II receptor antagonists based on current clinical understanding.

Main Results:

• ACE inhibitors provide proven long-term benefits for multiple cardiovascular and renal conditions.
• Alternative pathways for angiotensin II synthesis exist, independent of ACE.
• ACE inhibitors promote kinin accumulation, contributing to cardio- and renal protection via nitric oxide and prostacyclin release.

Conclusions:

• ACE inhibitors are valuable therapeutic agents with established long-term benefits.
• Understanding alternative pathways and the role of kinins refines the clinical application of ACE inhibitors.
• ACE inhibitors may be preferred over angiotensin II receptor antagonists due to additional kinin-mediated protective effects.