The Management of Hypertension With Angiotensin Receptor Blockers in Special Populations

Abstract

Angiotensin receptor blockers (ARBs) are the most recently approved major class of antihypertensive agents. The primary mechanism of action of ARBs is the selective blockade of the AT₁ receptor. There are 7 ARBs presently approved for clinical use in the United States, several with other indications in addition to blood pressure reduction in patients with hypertension. While ARBs appear to be no more potent than angiotensin-converting enzyme inhibitors for lowering blood pressure when used as monotherapy, they are a beneficial alternative and even compelling in certain populations. This class of agents also has the added benefit of placebo-like side effects, potentially enhancing adherence. In this review, studies are presented as positive evidence supporting the use of ARBs in special populations (including persons with diabetic nephropathy), in patients with heart failure (especially with systolic dysfunction), for cardioprotection in high-risk cardiac patients (including postmyocardial infarction and stroke), and for delaying new-onset diabetes. Clinical information on the effects of ARBs related to race and ethnicity are also discussed, although the data in most large trials are not substantial. Despite the fact that African American patients have the highest prevalence of hypertension (with increased mortality and morbidity), studies have been less robust regarding ARBs and protection against cardiovascular disease in this population. Although at least 1 major study has confirmed the benefit of ARBs in Asian patients with diabetic nephropathy, overall, treating patients based on race and ethnicity remains fraught with difficulty.