The effect of telmisartan and ramipril on early morning blood pressure surge: A pooled analysis of two randomized clinical trials

University of Leicester, Leiscester, England, United Kingdom
Blood Pressure Monitoring (Impact Factor: 1.53). 06/2007; 12(3):141-7. DOI: 10.1097/MBP.0b013e3280b10bbd
Source: PubMed


The period of early morning blood pressure surge is associated with a higher incidence of cardiovascular events than at other times of the day. Antihypertensive medication given once daily in the morning may not protect against this surge if its duration of action is too short. We compared telmisartan, an angiotensin II receptor blocker with a trough-to-peak ratio >90%, with ramipril, an angiotensin-converting enzyme inhibitor with a trough-to-peak ratio of around 50%.
Data from two prospective, randomized, open-label, blinded endpoint studies comparing telmisartan force titrated to 80 mg once daily and ramipril 10 mg once daily were pooled. Patients had mild-to-moderate hypertension and were assessed using 24-h ambulatory blood pressure monitoring at baseline and endpoint. Early morning blood pressure surge was defined as the difference between mean blood pressure within 2 h after arising and night-time low. Patients were grouped into quartiles according to their baseline systolic surge.
Data from 1279 patients were analyzed. Telmisartan changed the overall mean (SE) systolic surge by -1.5 (0.47) mmHg, and ramipril by +0.3 (0.47) mmHg (P=0.0049). The magnitude of surge reduction was greatest in the quartile with highest baseline systolic surge: telmisartan -12.7 (0.91), ramipril -7.8 (1.02) mmHg (P=0.0004). Telmisartan also reduced the surge compared with ramipril in dippers, but there were no differences between the two groups in nondippers.
Telmisartan significantly reduced the early morning systolic blood pressure surge compared with ramipril. A reduction in this surge may help to reduce cardiovascular events in the morning period.

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    • "Naturally, telmisartan was not only compared to placebo but, more interestingly, also compared to other antihypertensive agents, including ACE inhibitors and ARBs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 1 and 2 trials compared the efficacy of telmisartan 40–80 mg with that of ramipril 5–10 mg on 24-hour BP readings.23–25 BP decreased more sharply with telmisartan 80 mg than with ramipril 10 mg (–12.7/–8.8 "
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    ABSTRACT: Telmisartan, a selective angiotensin II type 1 receptor blocker (ARB), has been investigated in many trials, in particular, in order to assess its antihypertensive effect in various situations and its ability to protect organs susceptible to hypertension. In addition to its antihypertensive properties, it has positive metabolic and vascular effects (partly because of its sustained action). Several large-scale trials have focused on the effect of telmisartan on cardiovascular morbidity and mortality, including comparisons of that with an angiotensin-converting enzyme inhibitor in subjects at high vascular risk. Telmisartan was used in the largest ARB research programme (the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial [ONTARGET] and Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease [TRANSCEND] trial).
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    • "Differential effects between antihypertensive agents on the magnitude of reduction in the early morning hours have been shown in this and previous studies. Telmisartan has shown superiority in the early morning hours over several other antihypertensives, such as ramipril [21-23], losartan [24,25], and valsartan [9]. In two large studies, telmisartan 80 mg changed the overall mean systolic early morning surge by -1.5 mm Hg compared with a change of + 0.3 mmHg by the ACEi ramipril (p = 0.0049) [6]. "
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