Angiotensin converting enzyme inhibitors and the progress of antihypertensive therapy

Drug treatment of hypertension reduces morbidity and mortality most effectively in moderate to severe cases. However, most patients have only mild hypertension, for which traditional drug treatment is not consistently successful. Angiotensin converting enzyme (ACE) inhibitors provide superior control of mild hypertension. They have a haemodynamically favourable mechanism of action, are well tolerated and can produce a predictable response within a narrow and convenient dose range. Further, ACE inhibitors are lipidneutral, and they positively affect some of the mechanisms conducive to the development of atherosclerosis. Further research in this area is warranted. The ACE inhibitors may also help prevent end-organ damage in hypertensive patients who also have diabetes, kidney disease, left ventricular hypertrophy or a combination of these disorders. The case for renoprotection in diabetic hypertensives is strong enough to recommend preferential use of ACE inhibitors for these patients. The positive effects shown in left ventricular hypertrophy may also be produced by other modern antihypertensive agents, while the advantages of ACE inhibitors in essential hypertension with renal damage remain largely conjectural. There have been encouraging clinical results, but ongoing larger trials may provide a more definitive answer.