Journal of Hypertension. Supplement : Official Journal of the International Society of Hypertension

The early detection of cardiac organ damage in clinical practice is primordial for cardiovascular risk profiling of patients with hypertension. In this respect the determination of microalbuminuria is very appealing because it increasingly appears to be the most cost-effective means to identify cardiovascular and renal complications. Considering the treatment of patients with target organ damage, blockers of the renin-angiotensin system have a key position as they are very effective in regressing left ventricular hypertrophy, lowering urinary albumin excretion and delaying the progression of nephropathy...

No abstract text is available yet for this article.

Blockade of the renin-angiotensin system (RAS) has become an integral component of the treatment of patients at increased cardiovascular risk. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) studied 23 400 high-risk cardiovascular patients and compared the effectiveness of telmisartan with that of ramipril and showed that the two drugs were 'therapeutically equivalent'. Telmisartan is now the only angiotensin II blocker with clinical trial evidence of cardiovascular protection equivalent to that of ramipril, which is widely regarded as the 'reference' drug for RAS blockade in patients at increased cardiovascular risk...

'Hard' primary endpoints from randomized clinical trials, such as cardiovascular morbidity and mortality data are usually considered as the backbone of evidence for clinical practice guidelines. However, 'intermediate' or 'surrogate' endpoints, for example, biological or imaging markers are increasingly being recognized for their importance in stratifying risk and determining treatment strategy in clinical practice. In hypertension, use of validated surrogate endpoints, notably left ventricular hypertrophy (LVH), microalbuminuria, arterial stiffness and carotid intima-media thickness are discussed...

One major element of novelty of the 2007 European guidelines on hypertension refers to the concept of risk categorization, with the aim of obtaining a more precise definition of the hypertensive patient. This has lead to identification of different categories of cardiovascular risk, from the low to the very high. Studies performed in the past few years have shown that the very high risk category is quite common and it is not unusually accompanied by poor blood pressure control. Results of the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomized AssessmeNt Study in ACEI iNtolerant subjects with cardiovascular Disease (TRANSCEND) have allowed us to better define the therapeutic approach to high-risk patients showing the favorable effects of either ramipril or telmisartan on blood pressure control and risk profile...

Prevention of diabetes represents an important therapeutic goal in current cardiovascular risk reduction strategies. Blockade of the renin-angiotensin system has been shown to markedly reduce the incidence of new-onset diabetes in different patient populations. Recent results from three large clinical endpoint trials with the angiotensin-II receptor blocker telmisartan regarding new-onset diabetes, atrial fibrillation, and left ventricular hypotrophy will be discussed.

In patients with arterial hypertension and/or high cardiovascular risk, including patients with diabetes, chronic ischemic heart disease and kidney disease, the risk of heart failure decreases with blood pressure reduction and the use of drugs that inhibit the renin-angiotensin system (RAS) [angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)]. The heart failure incidence seen in ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) is in line with this observation...

Activation of the AT1 angiotensin II (Ang II) receptors has various effects including vasoconstriction, hypertrophy, and possibly hyperplasia of vascular smooth muscle cells and cardiomyocytes and increase in extracellular collagen matrix synthesis. These actions lead to the development of cardiovascular hypertrophy and fibrosis, as well as arterial stiffness, which are some key factors in the development of the cardiovascular and renal complications. In clinical studies, it has been shown that renin-angiotensin blockade has direct and specific implications in the evolution of heart failure, coronary disease, stroke, and hypertensive and diabetic renal disease...

Stroke is the second most frequent cause of death in the world and is responsible for about 5 million deaths each year. Several trials have raised the possibility that blocking the renin-angiotensin system (RAS) may be beneficial in patients with stroke. The recently reported Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) study evaluated the effect of lowering blood pressure with the angiotensin receptor blocker (ARB), telmisartan, initiated early after stroke. A total of 80 patients (8...

Angiotensin-converting enzyme (ACE) inhibitors are useful drugs for preventing cardiovascular disease and death in patients at risk. However, a significant proportion of patients experience side effects, mainly cough or less frequently angioedema, when treated with ACE inhibitors. Angiotensin receptor blockers (ARBs) are also useful drugs for treatment of hypertension, diabetic nephropathy and patients with left ventricular dysfunction or cardiac failure who are intolerant to ACE inhibitors. The Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) study examined the effect of a long-acting ARB, telmisartan, on cardiovascular events in a group of patients at high-risk for cardiovascular disease who were intolerant to ACE inhibitors...

Hypertension control in populations, although improving, remains far from satisfactory, even though effective and inexpensive therapies are available. Among many factors responsible for this situation, poor adherence to treatment appears to be particularly important. Unfortunately, even if its causes have been quite well defined, this problem is still far from being solved in clinical practice. The present paper discusses the key issues related to treatment adherence, and discontinuation in hypertension, in the light of recent evidence coming from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomized AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease trial (TRANSCEND)...

Inhibition of the renin-angiotensin system (RAS) either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) has been shown to be beneficial for cardiorenal protection. The combination of both is an exciting prospect and pathophysiologically plausible. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study provides evidence that dual blockade does not further reduce cardiovascular events or worsen renal outcomes. However, in patients with existing diabetic nephropathy, a trend towards a better outcome was observed...

Angiotensin II plays an important role in the cardiovascular continuum starting with risk factors and progressing to atherosclerosis, target organ damage, and ultimately to heart failure, stroke, or death. Inhibiting the renin-angiotensin-aldosterone system (RAAS) represents a cornerstone for the treatment of hypertension and heart failure. In patients with heart failure, the single RAAS blockade with angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce morbidity and mortality, increase life expectancy, and preserve the renal function...

No abstract text is available yet for this article.

Cardiovascular disease is responsible for 70% of all mortality among patients with type 2 diabetes and is also a major contributor to diabetes-related healthcare costs. The ADVANCE trial clearly demonstrated that a simple and easily applicable pharmacological strategy based on perindopril/indapamide fixed combination could substantially reduce total and cardiovascular mortality (-14% and -18%, respectively). The observed benefits were largely caused by a substantial decrease in systolic blood pressure (SBP), confirming the need to have ambitious therapeutic goals in such high-risk patients...

OBJECTIVES: To evaluate among individuals with diabetes whether major microvascular and macrovascular events are reduced by: (1) blood pressure lowering with a perindopril/indapamide combination compared with placebo; (2) intensive glucose control (targeting a haemoglobin A1c level of < or =6.5%) with a gliclazide MR-based regimen, compared with usual care. METHODS: Participants with diabetes aged 55 years and older with at least one additional vascular risk factor were randomly assigned, using a 2 x 2 factorial design, to additional blood pressure lowering versus placebo and intensive versus standard glucose control...

Difficulties in achieving a reduction in morbidity and mortality in patients with diabetes are a result of the complexity of the disease and its intertwined relationship with hypertension and renal impairment. In the recently published Action in Diabetes and Vascular disease: PreterAx and DiamicroN-MR Controlled Evaluation (ADVANCE) trial, treatment of patients with diabetes with the fixed combination perindopril/indapamide on top of background treatments provided clinically and statistically significant reductions in blood pressure (from 145/81 to 136/73 mmHg), all-cause mortality (-14%), cardiovascular mortality (-18%), major cardiovascular events (-9%), renal events (-21%) and new-onset microalbuminuria (-21%) when compared with placebo...

The need to prevent the development of renal damage and its associated increase in cardiovascular risk in patients with type 2 diabetes is well established. Early intervention to maintain strict blood pressure control and to prevent the development of microalbuminuria is mandatory and will constitute the primary aim of intervention in patients with diabetes and also in prediabetes, characterized by the presence of cardiometabolic risk. If microalbuminuria is already present, similar blood pressure control and normalized urinary albumin excretion are required...

No abstract text is available yet for this article.

This white paper is an urgent call to action from an international group of physicians. The continued failure to control hypertension takes an unacceptable toll on patients, families and society and it must be addressed. Any patient with blood pressure of 140/90 mmHg or greater can be characterized as a 'challenging patient', is at significant risk, and requires persistent optimization of therapy until target blood pressure is achieved. Six key challenges in reaching this goal blood pressure are described: (1) inadequate primary prevention; (2) faulty awareness of risk; (3) lack of simplicity; (4) therapeutic inertia; (5) insufficient patient empowerment; and (6) unsupportive healthcare systems...