The renin-angiotensin systems: Evolving pharmacological perspectives for cerebroprotection

During the last 20 years, the renin-angiotensin system (RAS) has become an increasingly important focus of basic and clinical cardiovascular research. One main conceptual step forward was made with the discovery of a tissue RAS and the understanging of its critical pathophysiological role in atherogenesis and plaque destabilisation [1]. Major effort to find new strategies for blocking the RAS has produced new classes of drugs which were expected to be clinically important in the management of hypertension and heart failure. As landmark clinical studies have demonstrated that inhibition of the RAS significantly reduces morbidity and mortality from coronary heart disease, myocardial infarction and heart failure, the concept has rapidly emerged that blocking the RAS was the strategy of choice for preventing cardiovascular diseases [2]. More recently, basic research has however continuously extended our understanding of the complexity of the systemic and tissue RASs, that can no longer be viewed as one-way streets in which one single effector, angiotensin 11 acts solely through its major (ATI) receptor. Meanwhile, clinical trials have challenged the concept that blocking the RAS is the most effective preventive strategy for all patients and all target organs [3]. Consistent with the recent understanding that the RAS encompasses a number of distinct effectors acting through different receptors to promote opposite effects, a growing body of basic and clinical evidence suggests that blunting the RAS is a double-edge sword, with beneficial effects counterbalanced by deleterious ones, resulting in a net effect that critically depends on the experimental conditions, or the clinical characteristics of the study population. Of particular clinical relevance, a number of clinical trials point to the somewhat provocative conclusion that beyond their blood pressure lowering effect antihypertensive drugs that decrease angiotensin 11 formation are less stroke protective than the ones that increase angiotensin levels [4]. This review focuses on the recent experimental evidence demonstrating that angiotensin 11 and its derivatives acting through the non-ATI receptors are involved in protective mechanisms against cerebral ischaemia and discusses in the light of the recent large cardiovascular prevention trials the clinical relevance of this new concept. The perspective of a renewal of therapeutical strategies to optimise the prevention of target organ damage and perhaps even some of the diseases of ageing, such as loss of cognitive function is emphasised.