michigan hypertension core curriculum - State of Michigan

(mean age, 54 years). Overall, ACE inhibitors were found to have a modest collective effect in reducing
BP. The mean reduction in SBP ranged between 6 mm Hg and 9 mm Hg, and the mean reduction
in DBP was 4-5 mm Hg. 11 It was notable that all the ACE inhibitors studied were homogeneous in
their efficacy and that lower doses were generally as effective in reducing BP as the manufacturer’s
maximum recommended doses. This observation can be most readily explained by the fact that ACE
inhibitors have relatively flat-dose-response curves.
ACE inhibitors are notable for a low incidence of side effects and ease of dosing. For this
reason they are very popular antihypertensive agents in clinical practice, though, as noted under the
diuretic section above, national guidelines continue to endorse the use of thiazide diuretics as first
line agents for the treatment of uncomplicated hypertension. They have traditionally been perceived
to be more effective in Caucasians and younger patients, though more recent data suggests they are
effective in African American patients, as well, with perhaps higher dosing. Race, however, should
never be sole criterion upon which an ACE inhibitor or any other antihypertensive agent is either
chosen or avoided. 12
The ACE inhibitors have pleiotropic effects on the renal and cardiovascular systems making
them ideal antihypertensive agents for specific medical populations. There is some evidence that they
have a beneficial effect on glucose metabolism (improve glucose tolerance without affecting fasting
glucose levels) and appear to delay the onset of type 2 diabetes. These agents reduce preload
and afterload, down-regulate sympathetic activity by blocking the facilitating effects of angiotensin II
on sympathetic nerves, and promote renal excretion of sodium and water by blocking the effects of
angiotensin II in the proximal tubule and by antagonizing angiotensin II-mediated aldosterone secretion.
ACE inhibitors also inhibit cardiac and vascular remodeling associated with chronic hypertension and
heart failure. All of these qualities make ACE inhibitors excellent antihypertensives for the treatment
of patients with heart failure and following myocardial infarction for which they have been shown
to reduce mortality in multiple clinical trials. Finally, there is abundant evidence from many clinical
trials demonstrating that the ACE inhibitors are effective in reducing proteinuria and decreasing the
rate of decline in kidney function in patients with chronic kidney disease. While strict control of BP
appears to be the most important in regards to preservation of kidney function, it also appears that the
ACE inhibitors have a beneficial effect on renal function – especially amongst those individuals with
NKFM & MDCH 193