Blockade of Renin Angiotensin System in Heart Failure Post-Myocardial Infarction: What is the Best Therapy?
Caio E. Gullo, Victor A. de Almeida Zia and Jose F. Vilela-Martin
Affiliation: State Medical School of São Jose do Rio Preto/SP (FAMERP), Av Brig Faria Lima 5416 – Postal Code: 15090-000, Sao Jose do Rio Preto/SP/Brazil.
Keywords: ACE blockers, ACE inhibitors, cardiovascular disease, heart failure, hypertension, ventricular remodelling.
Heart Failure (HF) is a progressive and fatal disorder, which ranks among the major public health
problems in Brazil and worldwide. However, survival for patients who developed the syndrome after myocardial
infarction (MI) enhanced significantly, as a result of an improvement of pharmacological therapies. A
medical breakthrough was the discovery that remodelling of the left ventricle (LV) may be limited by the blockade of the
renin-angiotensin system (RAS), at the level of angiotensin converting enzyme (ACE) and binding of angiotensin (Ang) II
to its AT1 receptor. This review shows that the therapeutic effects of both ACE inhibitors and the angiotensin receptor
blockers (ARB) go beyond the interference in the biochemical pathway ACE-Ang II AT1-receptor. Such effects are also
related to the potentiation of bradykinin and increased beneficial effects mediated by the AT2 receptor. Therefore, the results
of five randomized trials were presented, which evaluated the use of losartan, valsartan or candesartan, considering
their effects on survival and risk of clinical deterioration in patients with symptomatic HF after MI. These studies confirmed
the advantage of ARBs over inhibitors in case of cough, rashes and angioneurotic edema, despite similar adverse
effects, such as hyperkalemia, renal failure and hypotension. Thus, in this article we have discussed with patents that ACE
inhibitors also appear as the first option as RAS inhibitors in search of relevant results for the patient, allowing the alternative
use of ARBs to those patients with intolerance.
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