ACE-inhibitors and sartans - will large trials results published in 2008 change our every-day clinical practice?

Abstract

Sartans have been available for over 10 years. However, the debate concerning the adventage of sartans vs ACE inhibitors is still ongoing. Recently published results of large clinical trials have provided new arguments in this debate. Moreover, the benefits of sartans combined with ACE inhibitors have been widely suggested. One of the large trials published in 2008 also provides some new data in this field. The new published results suggest that telmisartan can be considered as an alternative agent for ramipril in patients with symptomatic atherosclerosis or diabetes, however, some important concerns were raised by significantly faster reduction of glomerular flow rate related to the use of telmisartan (ONTARGET trial). TRANSCEND trial showed that telmisartan moderately reduces the risk of cardiovascular death/stroke/myocardial infarction in intolerant to ACE inhibitors patients with symptomatic atherosclerosis or diabetes. However, there was no reduction in hospitalisations due to heart failure in this population. ONTARGET Trial Investigators failed to show any benefit from combination therapy consisted of ramipril and telmisartan. On the other hand this combination was related to higher frequency of of side effects, especially renal ones. Taking all the above into account it seems that the published in 2008 large clinical trials will not change actual guidelines concering treatment of hypertension in patients with symptomatic atherosclerosis or diabetes. ACE inhibitors remain the drugs of choice for these patients.