Should All Diabetic Patients Receive an ACE Inhibitor?
Should All Diabetic Patients Receive an ACE Inhibitor?
Diabetes is associated with both premature cardiovascular disease and renal disease. The presence of microalbuminuria is itself an independent risk factor for the development of cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors were initially shown to slow the progression of established renal disease in patients with type 1 diabetes. Subsequent trials have demonstrated a similar benefit in patients with type 2 diabetes and with the use of angiotensin II receptor blockers (ARBs). The use of ACE inhibitors to prevent cardiovascular events in patients with established cardiovascular disease but not left ventricular dysfunction was established in two large randomised trials - HOPE and EUROPA. These benefits were maintained within the diabetic subgroups of these trials and appear to be independent of blood pressure lowering. The LIFE trial also provides evidence of the benefits of ARBs in reducing cardiovascular events in a high-risk population of diabetic patients with hypertension and left ventricular hypertrophy. Ideally, therefore, all diabetic patients with renal or cardiovascular disease should be treated with ACE inhibitors or ARBs.
Many studies have confirmed the excessive cardiovascular morbidity and mortality in people with diabetes. In addition, between 25-50% of diabetic patients develop kidney disease. Only a proportion of these will require dialysis or transplantation as many die from premature cardiovascular disease prior to needing renal replacement therapy. Diabetic nephropathy is a progressive condition with early glomerular hyperfiltration followed by microalbuminuria, which progresses to frank proteinuria and end-stage renal disease. Microalbuminuria is also an independent marker of cardiovascular risk in patients with both type 1 and type 2 diabetes.
We discuss the rationale for inhibition of the renin-angiotensin system using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in patients with type 1 and 2 diabetes, and examine the benefits of blockade of the renin-angiotensin system on the progression of diabetic nephropathy and cardiovascular disease. We pose the question "should all diabetic patients receive an ACE inhibitor?"
Diabetes is associated with both premature cardiovascular disease and renal disease. The presence of microalbuminuria is itself an independent risk factor for the development of cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors were initially shown to slow the progression of established renal disease in patients with type 1 diabetes. Subsequent trials have demonstrated a similar benefit in patients with type 2 diabetes and with the use of angiotensin II receptor blockers (ARBs). The use of ACE inhibitors to prevent cardiovascular events in patients with established cardiovascular disease but not left ventricular dysfunction was established in two large randomised trials - HOPE and EUROPA. These benefits were maintained within the diabetic subgroups of these trials and appear to be independent of blood pressure lowering. The LIFE trial also provides evidence of the benefits of ARBs in reducing cardiovascular events in a high-risk population of diabetic patients with hypertension and left ventricular hypertrophy. Ideally, therefore, all diabetic patients with renal or cardiovascular disease should be treated with ACE inhibitors or ARBs.
Many studies have confirmed the excessive cardiovascular morbidity and mortality in people with diabetes. In addition, between 25-50% of diabetic patients develop kidney disease. Only a proportion of these will require dialysis or transplantation as many die from premature cardiovascular disease prior to needing renal replacement therapy. Diabetic nephropathy is a progressive condition with early glomerular hyperfiltration followed by microalbuminuria, which progresses to frank proteinuria and end-stage renal disease. Microalbuminuria is also an independent marker of cardiovascular risk in patients with both type 1 and type 2 diabetes.
We discuss the rationale for inhibition of the renin-angiotensin system using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in patients with type 1 and 2 diabetes, and examine the benefits of blockade of the renin-angiotensin system on the progression of diabetic nephropathy and cardiovascular disease. We pose the question "should all diabetic patients receive an ACE inhibitor?"
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