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Renin-angiotensin system inhibition in the treatment of hypertension

Johannes FE Mann, MD
Karl F Hilgers, MD
Section Editors
George L Bakris, MD
Norman M Kaplan, MD
Deputy Editor
John P Forman, MD, MSc


Inhibitors of the renin-angiotensin system (RAS), including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and direct renin inhibitors are commonly used in the treatment of hypertension. The role of the RAS in hypertension and the use of specific inhibitors of this system to treat hypertension will be reviewed here.

The use of RAS inhibitors in patients with kidney disease and diabetes are discussed separately. (See "Choice of drug therapy in primary (essential) hypertension" and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults" and "Treatment of hypertension in patients with diabetes mellitus" and "Treatment of diabetic nephropathy".)

The importance of local (ie, tissue) RAS activity in low-renin hypertension and the effects of angiotensin II on the heart are presented elsewhere. (See "Actions of angiotensin II on the heart".)


Since the introduction of captopril in 1977 [1], angiotensin-converting enzyme (ACE) inhibitors have become widely used for the treatment of hypertension and three of its major complications: acute myocardial infarction [2], congestive heart failure [3], and chronic kidney disease. Fifty to 60 percent of Caucasian patients have a good response to monotherapy with ACE inhibitors, a response rate similar to other first-line antihypertensive drugs [4]. ACE inhibitors have the additional advantages of having a more favorable side effect profile than sympathetic blockers, beta blockers, and diuretics [5], and of producing more regression of left ventricular hypertrophy than beta blockers [6]. (See "Clinical implications and treatment of left ventricular hypertrophy in hypertension", section on 'Choice of drugs'.)

Guidelines issued in 2009 by the European Society of Hypertension [7], and in 2011 by NICE (National Institute for Health and Clinical Excellence of Great Britain) [8], recommend the use of an ACE inhibitor or angiotensin II receptor blocker (ARB) in younger and non-black patients [9]. However, this recommendation is based upon relatively small cross-over trials [10].

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Literature review current through: Nov 2017. | This topic last updated: Jul 05, 2016.
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