1. Achieving the Clinical Potential of RAAS Blockade
The slides in this section provide practical information for clinical practice relative to the use of ACEI and ARB in patients.

2. 57-year-old African American male

3. Physical examination

4. Diagnostics

5. What is the diagnosis?

6. Impact of individual lifestyle modifications on systolic blood pressure
Adoption of individual lifestyle modifications have demonstrated significant reductions in systolic blood pressure (SBP); adopting 2 or more modifications has a cumulative effect.
Weight reduction may lead to a 5-20 mm Hg decrease in SBP per 10 kg of weight loss.
Aim for a BMI between 18.5 and 24.9 kg/m2.
Adopting the Dietary Approaches to Stop Hypertension (DASH) eating plan, which is rich in potassium and calcium, may lead to a 8-14 mm Hg decrease in SBP.
Consume a diet rich in fruits and vegetables, low-fat dairy, and foods low in saturated fat.
Dietary sodium reductions may lead to a 2-8 mm Hg decrease in SBP.
Sodium intake should be reduced to no more than 2.4 g sodium or 6 g table salt.
Increased physical activity may lead to a 4-9 mm Hg decrease in SBP.
Brisk walking or aerobic exercise for at least 30 minutes daily is suggested.
Moderation of alcohol consumption may lead to a 2-4 mm Hg decrease in SBP.
Alcohol consumption should be limited to 2 drinks per day for men and 1 drink per day for women.

7. JNC 7: Classification of blood pressure for adults
This slide provides a BP classification for adults 18 years of age or older.
Classification is based on the average of 2 or more properly measured, seated BP readings on each of at least 2 office visits
JNC 7 suggests that all subjects with hypertension (Stages 1 and 2) be treated.
Prehypertension identifies individuals at high risk of developing hypertension, so that patients and clinicians are alert to the possibility and take measures to prevent or delay that from happening.

8. AHA recommendations for prevention and management of IHD: BP targets
The American Heart Association (AHA) has recently issued a scientific statement on the treatment of hypertension in the prevention and management of ischemic heart disease, that recommends aggressive BP lowering.
A BP target of <120/80 mm Hg is recommended for the prevention and management of ischemic heart disease in patients with LV dysfunction.
A BP target of <130/80 mm Hg is recommended for the prevention and management of ischemic heart disease in a wide spectrum of high-risk patients with vascular disease, as shown on this slide.
A Class IIa recommendation signifies that although evidence is conflicting, the weight of the evidence/opinion is in favor of usefulness/efficacy of the recommendation.
Level of evidence B signifies that the data are derived from a single randomized trial or nonrandomized studies.

9. Factors for consideration

10. What are the clinical strategies?

11. AHA/ACC goals
Abbreviation:
ACC = American College of Cardiology

12. AHA/ACC guidelines for secondary CVD prevention—2006 Update: ACEI and ARB
This slide summarizes current AHA/ACC guidelines for use of ACEIs and ARBs for secondary prevention in patients with coronary and other atherosclerotic vascular disease.
ACEIs are recommended for a wide spectrum of patients, while ARBs are advised for use in ACEI-intolerant patients.

13. JNC 7 indications in hypertension management
Compelling indications for specific antihypertensive therapies involve high-risk conditions that can be direct outcomes of hypertension (HF, ischemic heart disease, chronic kidney disease, or recurrent stroke) or commonly associated with hypertension (ie, diabetes, high coronary disease risk).
Compelling indications for use of specific drug classes are based on evidence from clinical trials or recommendations in existing clinical guidelines.
Use of ARBs is recommended for patients with HF, diabetes, and chronic kidney disease, whereas ACEIs have broader compelling indications.
Note than the absence of a positive recommendation for a specific indication can simply signify a lack of information for a particular drug class (eg, in 2003 when JNC 7 was published).
Additional compelling indications for ACEIs, ARBs, and CCBs are anticipated.

14. AHA/ASA guidelines: BP recommendations after stroke or TIA
Among survivors of ischemic stroke or TIA, antihypertensive treatment is recommended for the prevention of recurrent stroke and other vascular events after the hyperacute period (Class I, level of evidence A).
Because this benefit extends to persons with and without a history of hypertension, antihypertensive therapy should be considered for all patients with ischemic stroke or TIA (Class IIa, level of evidence B).
An absolute BP level and target are uncertain and should be individualized, but an average reduction of ~10/5 mm Hg has proven to be beneficial, and JNC 7 has defined normal BP as levels as <120/80 mm Hg (Class IIa, level of evidence B).
Abbreviation:
ASA = American Stroke Association

15. HFSA 2006 HF Practice Guideline: ACEI and ARB in symptomatic/asymptomatic patients
ACEIs are recommended for prevention of HF in patients at high risk due to vascular disease or with T2DM and another major risk factor, or with T2DM who smoke or have microalbuminuria (Level of evidence A).
Routine ACEI is recommended in symptomatic and asymptomatic patients with left ventricular ejection fraction (LVEF) of 40% or less. (Level of evidence A).
ARBs are recommended in patients who cannot tolerate ACEIs because of cough (Level of evidence A).
ARBs may be considered as initial therapy rather than ACEIs in the following patients:
HF post-MI (Level of evidence A)
CHF and systolic dysfunction (Level of evidence B)
Consider adding an ARB for patients with HF due to systolic dysfunction if their symptoms persist or worsen on optimized ACE inhibition and beta-blockade.

16. RAAS modulation to reduce CV risk: Summary
RAAS modulation is a cornerstone of management strategies to reduce CV risk and there is considerable opportunity for expanded use of ACEIs and ARBs in high-risk patients.
Evidence indicates that both ACEIs and ARBs are first-line treatment for the protection of the cardiovascular, cerebrovascular, and renal systems.
Whereas ACEIs may be considered in all patients with vascular disease, ARBs are an effective and well-tolerated alternative in ACEI-intolerant patients.
Although ARBs have been less extensively studied than ACEIs, they may have similar or complementary protective effects.
Further insights into these issues may be provided by the results of several large ongoing trials.