Renin-Angiotensin System Blockade in Hypertension Management

Introduction to RAAS Blockade

• The American Diabetes Association recommends avoiding the combined use of ACE inhibitors and ARBs due to lack of benefit and increased risk of adverse events 1
• The American College of Cardiology/American Heart Association hypertension guidelines warn against simultaneous administration of renin-angiotensin system blockers, noting that it increases cardiovascular and renal risk 2

Risks Associated with Dual RAAS Blockade

• The European Society of Cardiology/European Society of Hypertension guidelines recommend that the combination of 2 renin-angiotensin system blockers is not recommended due to increased risks of hypotension, hyperkalemia, and changes in renal function 3
• Combining ACE inhibitors and ARBs is associated with increased risks of adverse events, including hyperkalemia and acute kidney injury, without providing additional benefit for cardiovascular or renal outcomes 1

Alternative Treatment Strategies

• The European Society of Cardiology/European Society of Hypertension guidelines recommend choosing one RAAS blocker, either an ACE inhibitor or an ARB, as the foundation of therapy, particularly for patients with diabetes with albuminuria, chronic kidney disease, heart failure, or high cardiovascular risk 3
• If blood pressure remains uncontrolled, guidelines recommend adding complementary agents, such as dihydropyridine calcium channel blockers, thiazide/thiazide-like diuretics, or a mineralocorticoid receptor antagonist, rather than combining ACE inhibitors and ARBs 4

Monitoring and Titration of RAAS Blockers

• When using a single RAAS blocker, monitor serum creatinine/eGFR and potassium levels at initiation and at least annually, and titrate to maximally tolerated doses for patients with albuminuria 4