ONTARGET: Use of ramipril, telmisartan, or both in patients with high cardiovascular risks

Abstract

Introduction: Angiotensin-converting enzyme (ACE) inhibitors have been shown to prevent cardiovascular events in high-risk patients in multiple studies. Among numerous trials, the use of ACE inhibitors was investigated for patients with left ventricular dysfunction [1], acute myocardial infarction (MI) [2], previous cardiovascular disease (CVD) or high-risk diabetes [3,4], and heart failure [5,6]. Additionally, the benefi t of angiotensin receptor blockers (ARBs) in high-risk patients with heart failure, MI, and left ventricular dysfunction was demonstrated in multiple studies [7–9]. However, ARB’s role in reducing the CVD events for high-risk patients without heart failure is not well defi ned. The renin-angiotensin system (RAS) plays an important role in hypertension, cardiovascular, and renal diseases. Because inhibition of RAS with ACE inhibitors or ARBs is usually incomplete due to various escape mechanisms [10,11], dual blockade of RAS with ACE inhibitors and ARBs appears to be an attractive medical treatment option. Combination therapy is supported by the recent meta-analysis in which combination therapy reduced proteinuria and blood pressure compared with monotherapy [12]; however, the fact that combination therapy leads to better clinical outcomes, such as reducing the CVD events, still remains controversial. Recent evidence from large trials and meta-analyses showed no additional clinical benefi t with combination therapy [13,14]. We reviewed the article on the recently published ONTARGET trial in which the effi cacy of telmisartan with or without ramipril in high-risk patients was investigated.