title: An update of the blockade of the renin angiotensin aldosterone system in clinical practice.
abstract: BACKGROUND
  Cardiovascular disease (CVD) is the leading cause of death worldwide. Blockade of this system is commonly used in the treatment of cardiovascular (CV) and renal disease.
  
  
  METHODS
  Data from multiple clinical trials have provided good evidence about the benefit of blocking the system as a therapeutic target to reduce CV and renal events. We have reviewed all the tested combinations of different drugs counteracting the effects of the renin-angiotensin-aldosterone system.
  
  
  CONCLUSIONS
  Monotherapy with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) remains valid in all the guidelines, whereas their dual combination has been discarded due to the absence of proven benefits in high CV risk patients and in patients with chronic kidney disease (CKD). The combination of the standard therapy with an ACEi or an ARB with a mineralocorticoid receptor blocker is a valid option, but has the inconvenience of frequent hyperkalemia in patients with CKD. Similarly, the addition of the direct renin inhibitor, aliskiren, to this standard therapy is not particularly supported in diabetic patients. New dual-acting blockers, for example, those combining valsartan and neprilysin inhibitors (LCZ696-Novartis) or endothelin converting enzyme inhibitors and neprilysin inhibitors (ECEI, Daglutril-Solvay), are currently under investigation.
authors.affiliation: a 1 Unidad de Hipertensión, Servicio de Clínica Médica, Hospital San Bernardo , Salta, Argentina.
authors.forename: Diego F
authors.initials: DF
authors.lastname: Márquez
authors.affiliation: b 2 Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Unidad de Hipertensión , Avda Cordoba s/n 28041, Madrid, Spain +349 143 177 41 ; +349 157 656 44 ; ruilope@ad-hocbox.com.|c 3 Universidad Complutense de Madrid (UCM), Instituto Pluridisciplinar , Madrid, Spain.
authors.forename: Gema
authors.initials: G
authors.lastname: Ruiz-Hurtado
authors.affiliation: b 2 Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Unidad de Hipertensión , Avda Cordoba s/n 28041, Madrid, Spain +349 143 177 41 ; +349 157 656 44 ; ruilope@ad-hocbox.com.|d 4 Universidad Autónoma, Departamento de Salud Pública y Medicina Preventiva , Madrid, Spain.
authors.forename: Luis M
authors.initials: LM
authors.lastname: Ruilope
authors.affiliation: b 2 Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Unidad de Hipertensión , Avda Cordoba s/n 28041, Madrid, Spain +349 143 177 41 ; +349 157 656 44 ; ruilope@ad-hocbox.com.
authors.forename: Julián
authors.initials: J
authors.lastname: Segura
mesh_terms: D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000188:drug therapy / Q000503:physiopathology; D004359:Drug Therapy, Combination; D006801:Humans; D006947:Hyperkalemia / Q000139:chemically induced; D051436:Renal Insufficiency, Chronic / Q000188:drug therapy / Q000503:physiopathology; D012084:Renin-Angiotensin System / Q000187:drug effects*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: aldosterone antagononists; angiotensin converting enzyme inhibitors; angiotensin receptor blockers; arterial hypertension; cardiovascular disease; chronic kidney disease; combination of rennin–angiotensin–aldosterone blockers; heart failure; renin inhibitor