Cardiovascular protection by angiotensin-converting enzyme inhibition

One of the most important health achievements during the twentieth century was the unravelling of the causes of the cardiovascular diseases (CVDs). Since the 1980s, coronary artery disease (CAD) mortality rates have been reduced in many developed countries and have fallen by 75% in countries such as Finland.1 Modern cardiovascular treatment has played an important role. The explosion in evidence-based treatments since the 1980s has provided us with the tools to increase life expectancy in those affected by the disease. The discovery of angiotensin-converting enzyme (ACE) inhibitors is one of these important tools. Ironically, ACE inhibitors come from the veins of poisonous snakes and yet their widespread use has saved millions of patients. Again, ironically, ACEs and the renin–angiotensin system have been and still are phylogenetically pivotal for the preservation of the species and for our daily life. The endpoint of the system is the production of angiotensin II, a potent vasoconstrictor and a growth factor essential to counteract bleeding and to repair the eventual hole in the vessel wall. Indeed, bleeding is a threat to mammalian survival and was a threat to primitive man, who was obliged to hunt to survive and therefore exposed to the risk of massive bleeding. Things have, however, changed. With evolution, hunting is often criticized as a sport rather than a necessity and bleeding is no longer a problem during our daily life. Once again, ironically, it is our very high standard of living and lifestyle that is the problem. Several attitudes, generally recognized as risk factors, through several complicated pathways, lead to hypertension and atherosclerosis and start a pernicious continuum of cardiovascular diseases.