A New Option for Therapeutic Management of Patients with Cardiovascular Disease

Therapeutic strategy aimed at global cardiovascular risk reduction represents a key priority for any prevention strategy, as clearly stated in the most recent international guidelines. In this view, therapeutic strategies based on ACE inhibitors have been demonstrated to significantly reduce cardiovascular morbidity and mortality in highrisk individuals. In the last decade, a long debate has developed in the scientific and medical community over whether the newer classes of antihypertensive agents, such as angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), have additional properties beyond blood pressure control, and therefore are superior to ACE inhibitors in terms of cardiovascular prevention. ARBs have been extensively investigated in a number of clinical conditions across the whole continuum of cardiovascular renal diseases, and these studies have prompted the use of these compounds as a first-line treatment for hypertension, as well as a treatment of choice in diabetic patients with nephropathy. The recently published ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) study, performed in a vast population of individuals at high risk, has challenged this substantially exclusive indication of ACE inhibitors, and namely of ramipril, by testing the non-inferiority of the ARB telmisartan and the hypothesis of a superiority of the combination of ramipril plus telmisartan compared with monotherapy with ramipril alone. The results of this study demonstrated that telmisartan was substantially equivalent to ramipril in high-risk patients in terms of cardiovascular protection, while the combination of the two drugs was associated with more adverse events without an increase in cardiovascular benefit.