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• W2004654005 abstract "Lionel Opie1Opie LH Renoprotection by angiotensin-receptor blockers and ACE inhibitors in hypertension.Lancet. 2001; 358: 1829-1831Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar sees angiotensin-receptor AT1 blockers as first-line treatment in diabetes type 2 nephropathy, with ACE inhibitors coming next, and calcium antagonists being kept for add-on therapy to lower blood pressure.In non-diabetic nephropathies the choices are less clear because, although the AASK trial showed a better renoprotection with ramipril than with amlodipine, despite a slightly higher mean blood pressure, a later metaanalysis of all the other trials showed that renoprotection with ACE inhibitors was associated with a significantly better blood-pressure control.We point out, however, that better blood-pressure control was also noted in the captopril trial in nephropathy of diabetes type 1, as well as for three trials with angiotensin-receptor blockers in type 2 diabetic nephropathy, with the exception of the comparison of irbesartan with amlodipine in which the blood-pressure control was strictly comparable. This point was acknowledged in the discussion of the RENAAL study, since the researchers did not exclude the role of a blood-pressure-dependent renoprotection with angiotensin-receptor blockers.Opie quotes the letter by Chrysostomou and colleagues,2Chrysostomou A Becket G Spironolactone in addition to ACE inhibition to reduce proteinuria in patients with chronic renal disease.N Engl J Med. 2001; 345: 925-926Crossref PubMed Scopus (217) Google Scholar who reported a reduction of proteinuria by addition of spironolactone to ACE inhibitors, and a significant fall in diastolic blood pressure of 12·5 mm hg. However, he does not stress at all the prominent role of non-hyperkalaemic diuretics and salt restriction in association with ACE inhibitors and angiotensin-receptor blockers for the control of proteinuria and blood pressure, as well as of hyperkalaemia prevention, which is a major side-effect of these drugs in advanced renal failure.The reason may be that there is only one medium-sized trial, which has compared diuretics directly with ACE inhibitors in 110 patients with diabetes type 2 and proteinuria. The researchers noted that hydrochlorothiazide was as effective as enalapril in preserving glomerular filtration rate as well as in reducing albuminuria for 3·5 years.3Walker W Hermann J Anderson J Randomized double blinded trial of enalapril versus hydrochlorothiazide on GFR in diabetic nephropathy.Hypertension. 1993; 22 (abstr): 410Google ScholarAnother reason for stressing the role of diuretics in cardiovascular and renal protection in diabetes is that they offer more stroke protection than do ACE inhibitors in hypertension primary prevention trials, as well as in stroke secondary prevention trials. This unexpected observation may be accounted for by the negative net effect of simultaneously blunting the angiotensin II non-AT1-receptor-mediated stroke protective mechanisms and the angiotensin II AT1-receptor-mediated proatherothrombotic effects4Fournier A Mazouz H Choukroun G Andrejak M Godefroy O The lowering of blood pressure after stroke.Lancet. 2001; 358: 1995Summary Full Text Full Text PDF PubMed Google Scholar in these populations with a low prevalence of coronary heart disease (⩽16%). As shown by the HOPE trial, the beneficial effect of angiotensin II AT1-receptor-mediated effects with ACE inhibitors is however preponderant in a population with a high prevalence of cardiovascular heart disease (80%),5Heart Outcomes Prevention Evaluation (HOPE) Study InvestigatorsEffects of angiotensin-converting-enzyme inhibitor on death from cardiovascular causes, myocardial infarction and stroke in high-risk patients.N Engl J Med. 2000; 342: 145-153Crossref PubMed Scopus (8126) Google Scholar so that it results in cardiac and brain protection.Since the angiotensin-receptor blockers will as efficiently blunt the angiotensin-II AT1-receptor activation as the ACE inhibitors, while stimulating angiotensin-II formation, they may have an edge over ACE inhibitors in stroke prevention by stimulating the angiotensin-II non-AT, receptor-mediated stroke protective mechanisms.4Fournier A Mazouz H Choukroun G Andrejak M Godefroy O The lowering of blood pressure after stroke.Lancet. 2001; 358: 1995Summary Full Text Full Text PDF PubMed Google ScholarTherefore, we fully support Opie's proposition for a comparative trial between ACE inhibitors and angiotensin-receptor blockers at an early stage of diabetic disease in the prevention of hypertension, microalbuminuria, and cardiac complications, and more specifcally in that of stroke, provided these two drugs are associated to diuretics. Lionel Opie1Opie LH Renoprotection by angiotensin-receptor blockers and ACE inhibitors in hypertension.Lancet. 2001; 358: 1829-1831Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar sees angiotensin-receptor AT1 blockers as first-line treatment in diabetes type 2 nephropathy, with ACE inhibitors coming next, and calcium antagonists being kept for add-on therapy to lower blood pressure. In non-diabetic nephropathies the choices are less clear because, although the AASK trial showed a better renoprotection with ramipril than with amlodipine, despite a slightly higher mean blood pressure, a later metaanalysis of all the other trials showed that renoprotection with ACE inhibitors was associated with a significantly better blood-pressure control. We point out, however, that better blood-pressure control was also noted in the captopril trial in nephropathy of diabetes type 1, as well as for three trials with angiotensin-receptor blockers in type 2 diabetic nephropathy, with the exception of the comparison of irbesartan with amlodipine in which the blood-pressure control was strictly comparable. This point was acknowledged in the discussion of the RENAAL study, since the researchers did not exclude the role of a blood-pressure-dependent renoprotection with angiotensin-receptor blockers. Opie quotes the letter by Chrysostomou and colleagues,2Chrysostomou A Becket G Spironolactone in addition to ACE inhibition to reduce proteinuria in patients with chronic renal disease.N Engl J Med. 2001; 345: 925-926Crossref PubMed Scopus (217) Google Scholar who reported a reduction of proteinuria by addition of spironolactone to ACE inhibitors, and a significant fall in diastolic blood pressure of 12·5 mm hg. However, he does not stress at all the prominent role of non-hyperkalaemic diuretics and salt restriction in association with ACE inhibitors and angiotensin-receptor blockers for the control of proteinuria and blood pressure, as well as of hyperkalaemia prevention, which is a major side-effect of these drugs in advanced renal failure. The reason may be that there is only one medium-sized trial, which has compared diuretics directly with ACE inhibitors in 110 patients with diabetes type 2 and proteinuria. The researchers noted that hydrochlorothiazide was as effective as enalapril in preserving glomerular filtration rate as well as in reducing albuminuria for 3·5 years.3Walker W Hermann J Anderson J Randomized double blinded trial of enalapril versus hydrochlorothiazide on GFR in diabetic nephropathy.Hypertension. 1993; 22 (abstr): 410Google Scholar Another reason for stressing the role of diuretics in cardiovascular and renal protection in diabetes is that they offer more stroke protection than do ACE inhibitors in hypertension primary prevention trials, as well as in stroke secondary prevention trials. This unexpected observation may be accounted for by the negative net effect of simultaneously blunting the angiotensin II non-AT1-receptor-mediated stroke protective mechanisms and the angiotensin II AT1-receptor-mediated proatherothrombotic effects4Fournier A Mazouz H Choukroun G Andrejak M Godefroy O The lowering of blood pressure after stroke.Lancet. 2001; 358: 1995Summary Full Text Full Text PDF PubMed Google Scholar in these populations with a low prevalence of coronary heart disease (⩽16%). As shown by the HOPE trial, the beneficial effect of angiotensin II AT1-receptor-mediated effects with ACE inhibitors is however preponderant in a population with a high prevalence of cardiovascular heart disease (80%),5Heart Outcomes Prevention Evaluation (HOPE) Study InvestigatorsEffects of angiotensin-converting-enzyme inhibitor on death from cardiovascular causes, myocardial infarction and stroke in high-risk patients.N Engl J Med. 2000; 342: 145-153Crossref PubMed Scopus (8126) Google Scholar so that it results in cardiac and brain protection. Since the angiotensin-receptor blockers will as efficiently blunt the angiotensin-II AT1-receptor activation as the ACE inhibitors, while stimulating angiotensin-II formation, they may have an edge over ACE inhibitors in stroke prevention by stimulating the angiotensin-II non-AT, receptor-mediated stroke protective mechanisms.4Fournier A Mazouz H Choukroun G Andrejak M Godefroy O The lowering of blood pressure after stroke.Lancet. 2001; 358: 1995Summary Full Text Full Text PDF PubMed Google Scholar Therefore, we fully support Opie's proposition for a comparative trial between ACE inhibitors and angiotensin-receptor blockers at an early stage of diabetic disease in the prevention of hypertension, microalbuminuria, and cardiac complications, and more specifcally in that of stroke, provided these two drugs are associated to diuretics." @default.
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• W2004654005 title "Renoprotection with antihypertensive agents" @default.
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