Pleiotropic effects of drugs inhibiting the renin-angiotensin-aldosterone system

The renin-angiotensin-aldosterone system blockade is a key component in the modern management of cardiovascular diseases. Agents that interfere with the different components of this system such as angiotensin converting enzyme inhibitors, sartans and mineralocorticoid receptor antagonists represent valuable therapeutic tools to reduce cardiovascular risk in brachial blood pressure independent mechanisms. Indeed, antagonists of the renin-angiotensin-aldosterone system reduce inflammation, oxidative stress and vascular remodeling in hypertension beyond blood pressure reduction and have demonstrated better cardiovascular protection compared with some of the other antihypertensive agents, especially in selected populations such as patients with diabetes and renal failure. These advantages were confirmed recently in several large-scale randomized trials. Latest evidence suggests that the effect of some antihypertensive drugs on central blood pressure is greater when compared with the effect on peripheral pressure. Nowadays, there is growing agreement that relatively greater influence of agents blocking renin-angiotensin system on central blood pressure may at least partly explain their advantages over other antihypertensives in many clinical situations. Clinical consequences of overestimation of the antihypertensive effect of some drug classes and underestimation blood pressure changes in patients treated with angiotensin converting enzyme inhibitors when analyzing brachial instead of central blood pressure is being increasingly recognized recently.