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Letters Dual blockade of the renin-angiotensin system

Sodium depletion in patients in clinical trials may account for the increased cardiovascular risk of dual blockade of the renin-angiotensin system

BMJ 2013; 346 doi: (Published 19 March 2013) Cite this as: BMJ 2013;346:f1685
  1. John H Laragh, professor of medicine, department of cardiothoracic surgery1,
  2. Jean E Sealey, research professor emerita of physiology and biophysics in medicine, department of medicine1
  1. 1Weill Cornell Medical College, New York, NY 10065-4896, USA
  1. jsealey{at}

Makani and colleagues’ meta-analysis of clinical trials of cardiovascular patients found that giving one renin-angiotensin system blocker reduces cardiovascular mortality but adding a second fails to reduce mortality and increases the frequency of hypotension, hyperkalaemia, and renal failure.1 We suspect that most adverse events occurred in sodium depleted patients who reactively increase plasma renin levels to vasoconstrict arterioles to …

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