title: Cardiovascular risk reduction in hypertension: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers. Where are we up to?
abstract: Previously, management of hypertension has concentrated on lowering elevated blood pressure. However, the target has shifted to reducing absolute cardiovascular (CV) risk. It is estimated that two in three Australian adults have three or more CV risk factors at the same time. Moderate reductions in several risk factors can, therefore, be more effective than major reductions in one. When managing hypertension, therapy should be focused on medications with the strongest evidence for CV event reduction, substituting alternatives only when a primary choice is not appropriate. Hypertension management guidelines categorise angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) interchangeably as first-line treatments in uncomplicated hypertension. These medications have different mechanisms of action and quite different evidence bases. They are not interchangeable and their prescription should be based on clinical evidence. Despite this, currently ARB prescriptions are increasing at a higher rate than those for ACEI and other antihypertensive classes. Evidence that ACEI therapy prevents CV events and death, in patients with coronary artery disease or multiple CV risk factors, emerged from the European trial on reduction of cardiac events with perindopril in stable coronary artery disease (EUROPA) and Heart Outcomes Prevention Evaluation (HOPE) trials respectively. The consistent benefit has been demonstrated in meta-analyses. The clinical trial data for ARB are less consistent, particularly regarding CV outcomes and mortality benefit. The evidence supports the use of ACEI (Class 1a) compared with ARB despite current prescribing trends.
authors.affiliation: Heart Failure Unit and Department of Cardiac Rehabilitation, Concord Repatriation General Hospital, Concord, New South Wales, Australia.
authors.forename: A
authors.initials: A
authors.lastname: Sindone
authors.affiliation: Faculty of Medicine, University of NSW, Sydney, New South Wales, Australia.|Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Erlich
authors.affiliation: Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
authors.forename: C
authors.initials: C
authors.lastname: Lee
authors.affiliation: Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.
authors.forename: H
authors.initials: H
authors.lastname: Newman
authors.affiliation: Liverpool Renal Clinical Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia.
authors.forename: M
authors.initials: M
authors.lastname: Suranyi
authors.affiliation: Department of Renal Medicine, Gosford Hospital, Gosford, New South Wales, Australia.
authors.forename: S D
authors.initials: SD
authors.lastname: Roger
mesh_terms: D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D055118:Medication Adherence; D017410:Practice Guidelines as Topic / Q000592:standards; D012307:Risk Factors; D040242:Risk Reduction Behavior
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents
keywords: angiotensin receptor antagonist; angiotensin-converting enzyme inhibitor; cardiovascular diseases; hypertension; risk assessment