Acute antihypertensive synergism of angiotensin-converting enzyme inhibitors and diuretics

In spontaneously hypertensive rats (SHR), after 1 day of dosing with an angiotensin-converting enzyme (ACE) inhibitor (captopril or enalapril) plus a diuretic (hydrochlorothiazide), a synergistic antihypertensive effect was observed when a second dose of the combination or ACE inhibitor alone but not the diuretic alone was given the next day. Bilateral ureteral ligation did not prevent the synergism, which indicates that diuresis per se was not the mechanism. Vascular responses to various agonists did not differ in SHR given ACE inhibitor or ACE inhibitor plus diuretic. SHR given combination treatment had higher and more prolonged increases in plasma renin activity. Aprotinin or indomethacin did not alter the synergism, which suggests that endogenous kinins and prostaglandins did not play a role. These data suggest that the mechanism for the synergistic antihypertensive effect resulted from the combination treatment's shifting the blood pressure regulation system to be renin dependent and responding more to drugs affecting the renin-angiotensin system (RAS). Evidence was presented that the RAS can be shifted rapidly to assume a greater role in blood pressure regulation in SHR as well as in normotensive and two-kidney, one-clip Goldblatt renal hypertensive dogs by restricting sodium intake. The data may partly explain the various degrees of antihypertensive responsiveness of essential hypertensive patients to ACE inhibitors.