ACE inhibition versus angiotensin receptor blockade: which is better for renal and cardiovascular protection?

Chronic renal disease is characterized by a gradual loss of renal function and an increased cardiovascular risk. Renin-angiotensin system blockade by angiotensin-converting enzyme inhibition or angiotensin receptor blockade has distinct renoprotective and cardiovascular protective effects, but which of the two drug classes confers more protection is still a matter of debate. This review highlights and compares the effects of the two drug-classes in nondiabetic renal disease and in overt or incipient nephropathy of type 1 and type 2 diabetes. Both renal and cardiovascular outcomes are considered. Regardless of their relative efficacy, both drug classes have a dose-response relationship for intermediate renal and cardiovascular parameters. Moreover, combined treatment with angiotensin-converting enzyme inhibition and angiotensin receptor blockade seems to provide better long-term renoprotection than monotherapy. Actually, in most patients, achieving maximal renal and cardiovascular protection requires a multidrug regimen, usually including several antihypertensives. Within this approach, full dose titration of either RAS blocker followed by add-on with the second drug is more important than the choice of the initial drug.