Telmisartan in High-Risk Cardiovascular Patients

Increasing attention is being devoted to the use of combination therapy with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in order to achieve maximal blockade of the renin–angiotensin system (RAS) in patients at high risk of cardiovascular events. This approach has been adopted in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET), which compared the effects of the ARB telmisartan and the ACE inhibitor ramipril, alone and in combination, on cardiovascular mortality and morbidity in high-risk patients with vascular disease or diabetes mellitus and end-organ damage. The results showed that telmisartan was as effective as ramipril for the primary cardiovascular outcome during a 56-month follow-up but was better tolerated. However, dual RAS blockade was not associated with any additional benefits, and the incidence of adverse events was greater with the combination. Based on these findings, optimal cardioprotective strategies in high-risk patients are likely to involve the addition of either telmisartan or ramipril on top of the patient's usual care, but not both. The choice of agent to be used in the long term could be based on other considerations, such as compliance and safety. Both cough and angioedema were higher with ramipril than telmisartan during the 56-month follow-up period in ONTARGET.