Angiotensin converting enzyme inhibitors and the progression of renal and vascular diseases: yes, but what also?

Since the discovery at the end of the seventies of angiotensin converting e nzyme inhibitors (ACEI), numerous clinical data became available in the ind ications for which these agents were initialy developed, taking into accoun t the putative role of renin angiotensin system: first in severe hypertensi on, secondly in moderate hypertension and then in heart failure. At the sam e time, an increasing interest was raised for "evidence based medicine,, le ading to a change in clinical study design: from clinical documentation of effects based on intermediate end points such as blood pressure, serum lipi ds, serum electrolytes or physical training capabilities to clear demonstra tions through double blind placebo controlled trial with a positive effect on morbi-mortality. This evolution was furthermore stimulated by advances o f knowledge on physiopatholigical mechanisms as well as the emergence of ne w drugs within this therapeutic class both stimulating clinical research. I n that prospective, three examples are obvious: treatment of myocardial inf arction, slowing down of the progression of diabetic nephropathy and of chr onic renal failure. All these new indications for ACEI were obtained though large morbi-mortality clinical studies which are reviewed in this article. Finally, clinical studies are running with ACEI in order to demonstrate a possible effect on primary or secondary prevention of cardiovascular morbi- mortality in high risk populations results which should be available at the beginning of the next century.