Angiotensin II Blockade and Total Cardiovascular Risk. Beyond Blood Pressure Reduction.

Hypertension is one of the world's largest public health problems and it is both a disease and a risk factor for cardiovascular disease (CVD). The heart, the endothelium and the kidneys are the target organs of hypertension. Recently, several antihypertensive drugs have been introduced to the market; therefore, the choice is mainly determined by the patients' features. In particular, ACE inhibitors and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) demonstrate a larger reduction in cardiovascular risk than other antihypertensive treatments because of the existence of blood pressure-independent effects. In fact, the angiotensin II pathway plays a major role in metabolic, haemodynamic and endothelial homeostasis. For these reasons, ACE inhibitors and ARBs have primary indications in patients with obesity, hypercholesterolaemia and diabetes mellitus because of their favourable metabolic properties. Furthermore, several large trials have demonstrated that they have favourable effects also in patients with left ventricular dysfunction or systolic heart failure, as well as other forms of heart disease. Drugs affecting the angiotensin II pathway may reduce endothelial dysfunction through several mechanisms including reduction of vascular permeability and oxidative stress. Another important effect of these drugs is neuroprotection. This is an important effect because in the near future, due to an aging population, an important goal for optimal antihypertensive treatment will be the prevention of cognitive decline. ACE inhibitors and ARBs are very important drugs in the modern management of the total cardiovascular risk in hypertensive patients.