Benefits from angiotensin-converting enzyme inhibition in patients with renal failure: latest results

Abstract

Epidemiological and clinical studies have shown that cardiovascular disease is a major contributory factor to high morbidity and mortality in patients with end-stage renal disease (ESRD). This excess mortality is related principally to left ventricular hypertrophy (LVH) and increased arterial stiffness and their interaction. Recent findings have indicated that aortic pulse wave velocity (PWV), a marker of aortic stiffness, is a strong independent predictor of cardiovascular and all-cause mortality in patients with ESRD who are on haemodialysis. Furthermore, it was shown in a therapeutic trial that the lack of aortic PWV attenuation despite significant druginduced reduction in blood pressure was a significant predictor of cardiovascular death in patients with ESRD. Moreover, the absence of PWV attenuation was associated with lack of regression of LVH, which by itself was associated with poor outcome. Controlled trials have also shown that angiotensin-converting enzyme inhibitors are the most efficient drugs for regression of LVH. Moreover, independently of its effects on left ventricular mass and blood pressure, the prescription of the ACE inhibitor perindopril, whether in combination or alone, had a strong and independent beneficial impact on all-cause and cardiovascular survival. After adjustment for all confounding factors, the risk ratio for perindopril use was 0.19 for all-cause mortality and 0.18 for cardiovascular mortality. These results indicate that, in patients with ESRD, improvement in arterial stiffness and regression of LVH are associated with a better prognosis and that the use of the ACE inhibitor perindopril has a favourable effect on survival that is independent of haemodynamic alterations.