Hemmung des Renin–Angiotensin–Aldosteron–Systems – Wirkstoffe, Kombinationen und Wirkungsweise

Abstract

The renin-angiotensin-system is mainly involved in the development and progression of hypertensive end-organ damage. Beside vasoconstrictive actions, Angiotensin II has many pathophysiological effects causing inflammation, endothelial dysfunction, fibrosis and tissue remodeling. Goals of antihypertensive treatment are blood pressure lowering per se and target endorgan protection (heart, brain, kidneys, vessels, eye) to improve cardio-vascular morbidity and mortality. ACE inhibitors and AT 1 receptor blockers are first-line antihypertensive agents and superior in the delay of progression of renal disease in patients with proteinuria (evidence level A). ACE inhibitors and AT 1 receptor blocker are indicated in hypertensive patients with diabetic nephropathy (randomised controlled trials with ACE inhibitors in type 1 diabetics, with AT 1 receptor blockers in type 2). ACE inhibitors and AT 1 receptor blockers are cardioprotective in hypertensive patients with left ventricular hypertrophy, in heart failure, after myocardial infarction and can be preventive of atrial fibrillation. Direct renin inhibition with aliskiren is appropriate for the combined antihypertensive treatment. The addition of an AT 1 receptor blocker to an ACE inhibitor can be beneficial in patients with refractory hypertension, heart failure, or proteinuria > 1 g/day despite optimum blood pressure control. Under treatment with a combination of an ACE inhibitor and an AT 1 receptor blocker or the use of an aldosterone blocker tests of serum potassium and creatinine values are indicated to prevent serious hyperkalemia. Blocker of the renin-angiotensin system are contra-indicated in pregnancy because of the risk of fetal deformities.