Guidelines for the treatment of hypertension allow a wide range of choices to the physicians; however some differences are present about the preferred drugs to start treatment. The most important aim remains an adequate decrease of blood pressure, something not perfectly obtained in the general population, but some classes of anti-hypertensive drugs could show protective effects on cardiovascular events, which are independent from blood pressure levels (the so called effects beyond blood pressure control). In this context antagonists of the renin-angiotensin system may represent an important help for the physicians, keeping in mind the preclinical studies showing the central role of the renin-angiotensin system not only in the regulation of blood pressure but also in the atherothrombotic processes.
The demonstration of an additional favourable effect of renin-angiotensin system blockers is not so obvious and frequently debated in the literature. Evidence-based medicine suggests that in patients at moderate/high cardiovascular risk it is difficult to have clear evidence of a specific advantage of some drug classes with respect to the others. However renin-angiotensin system blockers maintain compelling indications in particular cardiovascular situations; in addition analysis of intermediate end points, such as microalbuminuria, left ventricular hypertrophy, and arterial stiffness, gives further support to a drug-based anti-hypertension strategy. Last but not least, the optimal safety profile of these drugs, in particular of angiotensin II receptor blockers and renin inhibitors, allows their use in the very early stage of the hypertensive situation, as suggested by recent clinical trials.