Authors’ reply to Laragh and SealeyBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1689 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1689
All rapid responses
Sodium depleted patients are at risk from both single and dual renin-angiotensin system blockade.
The response of Messerli et al(1) to our suggestion(2,3) - that subsets of treated cardiovascular patients are sodium depleted with high plasma renin (PRA) levels and cannot benefit from renin-angiotensin system (RAS) blocking drugs - is typical of the current "one size fits all" approach to the treatment of patients with cardiovascular disease. Messerli et al conclude that "these risk benefit considerations argue against dual blockade regardless of the state of sodium depletion".
We believe that sodium depleted patients who are at risk of dual blockade are also at risk from single blockade. Moreover, hypertensive patients with very high PRA levels may need dual blockade to effectively block their high PRA levels and reduce their high blood pressure.
In sum, if PRA levels are monitored and interpreted appropriately in relation to blood pressure levels in individual patients, it is possible to discriminate patients who are at risk from RAS blocking drugs from those who may benefit from more than one. Such plasma renin test guided Precision Medicine has already been developed for hypertensive patients and is available on an App (PRA HTN)(4). With more experience, a similar targeted approach could be developed for the treatment of patients with cardiovascular disease as well.
1. Messerli et al BMJ 2013;346:f1689
2. Laragh JH, Sealey JE. BMJ 2013;346:f1685
3. Sealey JE, Alderman MH, Furberg CD, Laragh JH. Renin-angiotensin system blockers may create more risk than reward for sodium depleted cardiovascular patients with high plasma renin levels. Am J Hypertens 2013;26:eApril 2.
Competing interests: No competing interests