Angiotensin II receptor blockers and cardiovascular outcomes: the evidence now and in the future

The blood-pressure-lowering efficacy of both angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers; (ARBs) has been clearly demonstrated in recent years, although there is evidence that within the ARB class the individual therapies are not necessarily identical in terms of sustained and consistent antihypertensive efficacy over the entire dosing period. However, the results of the recent HOPE study have demonstrated that ACE-I have a wider role to play in treating cardiovascular disease, and support the idea that ACE inhibition specifically has a vascular protective effect. The most dramatic benefits were seen in patients with systolic blood pressures in the hypertensive range. The ability of the ACE-I to provide protective effects beyond blood pressure control may be due to their ability to attenuate the breakdown of kinins as well as a role in reducing angiotensin IL These data pose the question as to whether the pharmacological properties of the ARBs, in addition to their antihypertensive efficacy, may also play a significant role in influencing cardiovascular outcomes. A number of prospective long-term studies, including VALUE, SCOPE, LIFE, VALIANT, OPTIMAAL, VAL-HEFT and CHARM I-III, are investigating the effects of the ARBs of mortality and morbidity in patients with cardiovascular disease. These studies should answer important questions with respect to the role that ARBs may have in influencing cardiovascular outcomes, although it remains to be seen whether ARBs can match the protective effects of ramipril in high-risk patients. Given the excellent tolerability of the ARBs, it will be of value to examine the influence of ARBs on cardiovascular outcomes in all relevant patient groups.