Targeting blood pressure in the management of total cardiovascular risk

An overwhelming body of evidence has shown that lowering blood pressure (BP) reduces the risk of cardiovascular events, irrespective of the mechanism of action of the agent. Consistent control of BP is of crucial importance. Treatment should effectively lower BP both in the office and out of the office, and BP control should be achieved throughout the 24-h dosing interval. Agents with long half-lives and long duration of action should be considered for therapy. Tolerability is also an important attribute in anti-hypertensive therapy; both physicians and patients report poor tolerability as a key reason for discontinuing or switching therapy. Telmisartan is an example of an anti-hypertensive agent that provides strong BP reductions and smooth control of 24 h BP. It has greater BP-lowering efficacy than losartan, and also reduces BP towards the end of the dosing interval compared with valsartan. In the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial, the largest outcome trial with an angiotensin II receptor blocker and with the broadest cross section of cardiovascular high-risk patients, telmisartan was as protective as ramipril in reducing cardiovascular risk but better tolerated. Notably, the discontinuation rate for telmisartan was consistently lower than that for ramipril despite patients being screened for angiotensin-converting enzyme inhibitor tolerance, which suggests that the differences in tolerability may have practical implications for long-term cardiovascular protection.