Update on renin-angiotensin-aldosterone blockade in heart failure

Opinion statement

There is convincing evidence that the renin-angiotensin-aldosterone system (RAAS) plays an important role in heart failure (HF), from the events that result in its inception through advanced disease. In particular, RAAS activation is one of the major pathways involved in maladaptive cardiac remodeling, a process that results in progressive cardiac dysfunction. Not surprisingly, strategies targeting the RAAS have substantial benefits in HF. These therapies, which include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists, have emerged as cornerstones of HF therapy, particularly in patients with systolic dysfunction. Their role in HF with preserved ejection fraction, however, is less certain. New information and approaches targeting RAAS activation continue to emerge. Direct renin inhibitors are hypothesized to have beneficial effects in HF, but further studies are needed to evaluate their efficacy.