Evolving treatment options for prevention of cardiovascular events in high-risk hypertensive patients

Abstract

The identification and treatment of high-risk patients for cardiovascular disease reduces the risk of morbidity and mortality. Significant risk factors for cardiovascular events in hypertensive patients over and above dyslipidemia, smoking, and obesity include coronary heart disease, peripheral arterial disease, cerebrovascular/carotid artery disease, and diabetes. Treatment options for the reduction of cardiovascular events in hypertensive patients include diuretics, beta-blockers, alpha-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aldosterone antagonists. All of these agents, in various combinations, have been found to reduce the risk of cardiovascular events, even in high-risk patients. The use of ACE inhibitors or ARBs (usually in combination with a diuretic) has proven especially effective in reducing cardiovascular events in diabetes and, although both classes of drugs target the renin-angiotensin-aldosterone system, each has a different mechanism of action. Some investigators believe that combination therapy with an ACE inhibitor and ARB, usually given with other medications, may be more effective than either agent alone with other drugs. The Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) is evaluating the cardioprotective effect of an ACE inhibitor (ramipril) plus an ARB (telmisartan) in high-risk patients.

Figure 1

Ten‐year risk for coronary heart disease (CHD) by systolic blood pressure (SBP) and the presence of other cardiovascular risk factors. The risk of cardiovascular disease increases with increasing blood pressure and the presence of additional risk factors. HDL indicates high‐density lipoprotein; LVH, left ventricular hypertrophy. Adapted with permission from the Seventh Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. ⁷

Figure 2

Mean systolic and diastolic blood pressures in patients with type 2 diabetes, hypertension, and microalbuminuria treated with either candesartan, lisinopril, or their combination. Adapted with permission from Mogensen et al. ³⁷