title: CORD: COmparsion of Recommended Doses of ACE inhibitors and angiotensin II receptor blockers. Effect of valsartan and ramipril on atrial fibrillation recurrence and P-wave dispersion in hypertensive patients with recurrent symptomatic lone atrial fibrillation. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. Beneficial effect of lisinopril plus telmisartan in patients with type 2 diabetes, microalbuminuria and hypertension. The Hong Kong diastolic heart failure study: a randomised controlled trial of diuretics, irbesartan and ramipril on quality of life, exercise capacity, left ventricular global and regional function in heart failure with a normal ejection fraction Telmisartan, ramipril, or both in patients at high risk for vascular events. Different actions of losartan and ramipril on adipose tissue activity and vascular remodeling biomarkers in hypertensive patients Comparison of the effects of quinapril and irbesartan on P-wave dispersion in hypertensive patients A prospective evaluation of persistence on antihypertensive treatment with different antihypertensive drugs in clinical practice Rationale, design, and baseline characteristics of 2 large, simple, randomized trials evaluating telmisartan, ramipril, and their combination in high-risk patients: the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial/Telmisartan Randomized Assessment Study in ACE Int Effect of Treatment With Candesartan or Enalapril on Subcutaneous Small Artery Structure in Hypertensive Patients With Noninsulin-Dependent Diabetes Mellitus Aggressive antihypertensive therapy based on hydrochlorothiazide, candesartan or lisinopril as initial choice in hypertensive type II diabetic individuals: effects on albumin excretion, endothelial function and inflammation in a double-blind, randomized clinical trial Renoprotection of Optimal Antiproteinuric Doses (ROAD) Study: a randomized controlled study of benazepril and losartan in chronic renal insufficiency. Augmentation of myocardial blood flow in hypertensive heart disease by angiotensin antagonists: a comparison of lisinopril and losartan. Valsartan: long-term efficacy and tolerability compared to lisinopril in elderly patients with essential hypertension. Efficacy of ACE inhibitors and ATII receptor blockers in patients with microalbuminuria: a prospective study Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial Comparison of telmisartan with lisinopril in patients with mild-to-moderate hypertension. Combination treatment of angiotensin-II receptor blocker and angiotensin-converting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomised controlled trial. Long-term comparison of losartan and enalapril on kidney function in hypertensive type 2 diabetics with early nephropathy. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. Aggressive antihypertensive strategies based on hydrochlorothiazide, candesartan or lisinopril decrease left ventricular mass and improve arterial compliance in patients with type II diabetes mellitus and hypertension Effects of valsartan or ramipril addition to amlodipine/hydrochlorothiazide combination on left ventricular mass in diabetic hypertensive patients with left ventricular hypertrophy Effect of quinapril or losartan alone and in combination on left ventricular systolic and diastolic functions in asymptomatic patients with diabetic autonomic neuropathy. Effects of telmisartan and enalapril on renoprotection in patients with mild to moderate chronic kidney disease. Low doses of losartan and trandolapril improve arterial stiffness in hemodialysis patients. Comparison of the effects of angiotensin receptor antagonist, angiotensin converting enzyme inhibitor, and their combination on regression of left ventricular hypertrophy of diabetes type 2 patients on recent onset hemodialysis therapy. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II A comparison of the effects of ramipril and losartan on blood pressure control and left ventricle hypertrophy in patients with autosomal dominant polycystic kidney disease
abstract: OBJECTIVES The CORD trials tested ramipril and losartan in patients with hypertension . PATIENTS AND METHODS CORD IA involving switching from an angiotensin-converting enzyme inhibitor ( ACEI ) to the angiotensin II receptor blocker ( ARB ) losartan .  4,016 patients with blood pressure ( BP ) < 160/100 mm Hg who had been treated with an ACEI for > 3 months were enrolled . The mean age was 62.6 + /- 11.6 years and 53.1 % were women . The patients discontinued ACEI and switched to losartan 50 mg once daily .  BP , heart rate , biochemistry , blood counts and ECGs were measured at day 1 and months 1 , 3 , 6 and 12 . If the BP was > or = 140/90 mm Hg after 1 month or more , the dose of losartan was increased to 100 mg . After 1 month the BP decreased from 147.4 + /- 14.8/87.7 + /- 9.3 mm Hg to 139.7 + /- 11.8/83.0 + /- 9.3 mm Hg ( p < 0.001 ) and after 1 year to 133.7 + /- 11.3/79.1 + /- 7.06 mm Hg ( p < 0.001 ) . The rate of adverse events did not significantly increase and no changes in plasma sodium , potassium , urea or creatinine were observed . CORD IB compared ramipril and losartan . 3,813 patients with BP > or = 140/90 mm Hg who were not being treated with an ACEI or ARB were enrolled . The mean age was 60.5 + /- 12.2 years and 50.5 % were women . The patients were r and omised to ramipril 5 mg ( n = 1,926 ) or losartan 50 mg ( n = 1,887 ) . The dose was doubled if BP after 1 month was > or = 140/90 mm Hg . If the BP after 3 months still was > or = 140/90 mm Hg , another antihypertensive drug was added , typically athiazide diuretic . RESULTS After 1 yearthe BP decreased in the ramipril group from 155.9 + /- 13.1/93.0 + /- 8.9 mm Hg to 134.1 + /- 11.2/81.5 + /- 6.8 mm Hg ( p < 0.001 ) and in the losartan group from 156.5 + /- 13.1/93.4 + /- 8.8 to 134.55 + /- 11.3/80.16 + /- 6.6 mm Hg ( p < 0.001 ) . No significant differences were found between the groups . A slight increase in plasma potassium ( 0.2 mmol in both groups ) and urea ( 0.3 mmol in both groups ) was observed , but no change in plasma creatinine . There was a small , insignificant decrease in plasma uric acid ( in the ramipril group from 325.5 to 320.7 micromol/l and in the losartan group from 321.6 to 318.3 micromol/l ) and a slight decrease in plasma glucose and triglycerides ( 0.2 mmol/l in both measures in both groups ) . No severe adverse events were observed , but dry cough was 8 times more frequently reported in the ramipril group . CONCLUSION CORD IA confirmed that switching from an ACEI to losartan is safe and effective . Titrating the dose upwards or adding diuretics leads to good BP control in the majority of patients ( 2/3 ) . CORD IB showed no differences between ramipril and losartan in lowering BP and both drugs showed a trend to improve metabolic parameters such as glycaemia , triglyceridaemia and uric acid equally . Dry cough was more frequent after ACEI BACKGROUND This study compared the effect of antihypertensive treatment with valsartan or ramipril on  atrial fibrillation ( AF ) recurrence  , on P-wave dispersion , ( PWD ) and on serum procollagen type I carboxy terminal peptide ( PIP ) . METHODS A total of 369 mild hypertensive ( systolic blood pressure ( SBP ) > 140 and /or 90 < diastolic blood pressure ( DBP ) < 110 mm Hg ) out patients in sinus rhythm but with at least two episodes of AF in the previous 6 months were r and omized to valsartan ( n = 122 ) , ramipril  ( n = 124 ) , or amlodipine  ( n = 123 ) for 1 year . Clinic blood pressure ( BP ) and a 24-h electrocardiogram ( ECG )  were evaluated monthly . Patients were asked to report any episode of symptomatic AF and to perform an ECG as early as possible . PWD and serum PIP levels were evaluated before and after each treatment period . RESULTS SBP and DBP were significantly reduced by the three treatments ( P < 0.001 ) . A total of 46 ( 47.4 % ) patients treated with amlodipine had a recurrence of AF as did 26 ( 27.9 % ) patients treated with ramipril ( P < 0.01 vs. amlodipine ) and 16 ( 16.1 % ) patients treated with valsartan ( P < 0.01 vs. amlodipine and P < 0.05 vs. ramipril ) . The Kaplan-Meyer analysis showed a significant reduction of AF episodes in the valsartan group ( P = 0.005 log-rank test ) as well as in the ramipril group ( P = 0.021 ) , even if at a lesser degree . PWD values were significantly reduced by ramipril ( -4.2 ms , P < 0.05 ) and even more by valsartan ( -11.2 ms , P < 0.01 ) , the difference being significant ( P < 0.01 ) . Serum PIP levels were reduced by ramipril ( -49.7 microg , P < 0.001 ) and valsartan ( -49.3 microg , P < 0.001 ) . CONCLUSIONS Despite similar BP lowering , valsartan and ramipril were more effective than amlodipine in preventing new episodes of AF , but the effect of valsartan was greater than that of ramipril . This could be related to the greater PWD reduction observed with valsartan BACKGROUND Few studies have directly compared the renoprotective effects of angiotensin II-receptor blockers and angiotensin-converting-enzyme ( ACE ) inhibitors in persons with type 2 diabetes . METHODS In this prospect i ve , multicenter , double-blind , five-year study , we r and omly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan ( 80 mg daily , in 120 subjects ) or the ACE inhibitor enalapril ( 20 mg daily , in 130 subjects ) . The primary end point was the change in the glomerular filtration rate ( determined by measuring the plasma clearance of iohexol ) between the baseline value and the last available value during the five-year treatment period . Secondary end points included the annual changes in the glomerular filtration rate , serum creatinine level , urinary albumin excretion , and blood pressure ; the rates of end-stage renal disease and cardiovascular events ; and the rate of death from all causes . RESULTS After five years , the change in the glomerular filtration rate was -17.5 ml per minute per 1.73 m2 ( where the minus sign denotes a decrement ) in the telmisartan-treated subjects , as compared with -15.0 ml per minute per 1.73 m2 in the enalapril-treated subjects ; the treatment difference was thus -2.6 ml per minute per 1.73 m2 ( 95 percent confidence interval , -7.1 to 2.0 ml per minute per 1.73 m2)[corrected ] The lower boundary of the confidence interval , in favor of enalapril , was greater than the predefined margin of -10.0 ml per minute per 1.73 m2 , indicating that telmisartan was not inferior to enalapril . The effects of the two agents on the secondary end points were not significantly different after five years . CONCLUSIONS Telmisartan is not inferior to enalapril in providing long-term renoprotection in persons with type 2 diabetes . These findings do not necessarily apply to persons with more advanced nephropathy , but they support the clinical equivalence of angiotensin II-receptor blockers and ACE inhibitors in persons with conditions that place them at high risk for cardiovascular events Angiotensin-converting enzyme ( ACE ) inhibitors have favourable effects on hypertension and diabetic nephropathy , but persistent use may result in incomplete blockade of the renin-angiotensin system . Long-term effects of dual blockade using the ACE inhibitor lisinopril and the long-acting angiotensin II receptor blocker ( ARB ) telmisartan on blood pressure and albumin excretion rate ( AER ) were evaluated . Patients with type 2 diabetes mellitus , hypertension ( systolic blood pressure [ SBP ] > or=140 mmHg or diastolic blood pressure [ DBP ] > or=90 mmHg ) and microalbuminuria ( AER 30 - 300 mg/24h ) received 20 mg of lisinopril or 80 mg of telmisartan once a day for 24 weeks . Patients were then r and omised to continuing treatment with the respective monotherapy or with lisinopril plus telmisartan for a further 28 weeks . Significant ( P<0.001 ) declines in SBP ( 11.1 mmHg versus 10.0 mmHg ) , DBP ( 5.6 mmHg versus 5.3 mmHg ) and AER ( 98 mg/24 h versus 80 mg/24 h ) were achieved with lisinopril ( n=95 ) or telmisartan ( n=97 ) , respectively , after 24 weeks . Subsequent treatment with lisinopril plus telmisartan for 28 weeks result ed in further significant reductions ( P<0.001 ) in SBP , DBP and AER compared with either monotherapy . All treatments were well tolerated . Lisinopril plus telmisartan thus provides superior blood pressure and AER control than either monotherapy . We conclude that use of dual blockade may provide a new approach to prevention of diabetic nephropathy in patients with type 2 diabetes , hypertension and microalbuminuria Background : Although heart failure with a preserved or normal ejection fraction ( HFNEF or diastolic heart failure ) is common , treatment outcomes on quality of life and cardiac function are lacking . The effect of renin – angiotensin blockade by irbesartan or ramipril in combination with diuretics on quality of life ( QoL ) , regional and global systolic and diastolic function was assessed in HFNEF patients . Methods : 150 patients with HFNEF ( LVEF > 45 % ) were r and omised to ( 1 )  diuretics alone , ( 2 ) diuretics plus irbesartan , or ( 3 ) diuretics plus ramipril .  QoL , 6-minute walk test ( 6MWT ) and Doppler echocardiography were performed at baseline , 12 , 24 and 52 weeks . Results : The QoL score improved similarly in all three groups by 52 weeks ( −46 % , 51 % , and 50 % respectively , all p<0.01 ) , although 6MWT increased only slightly ( average + 3–6 % ) . Recurrent hospitalisation rates were equal in all groups ( 10–12 % in 1 year ) . At 1 year , LV dimensions or LVEF had not changed in any group , though both systolic and diastolic blood pressures were lowered in all three groups from 4 weeks onwards . At baseline both mean peak systolic ( Sm ) and early diastolic ( Em ) mitral annulus velocities were reduced , and increased slightly in the diuretic plus irbesartan ( Sm 4.5 ( SEM 0.17 ) to 4.9 ( SEM 0.16 ) cm/sec ; Em 3.8 ( SEM 0.25 ) to 4.2 ( SEM 0.25 ) cm/sec ) and ramipril ( Sm 4.5 ( SEM 0.24 ) to 4.9 ( SEM 0.20 ) cm/sec ; Em 3.3 ( SEM 0.25 ) to 4.04 ( SEM 0.32 ) cm/sec ) groups ( both p<0.05 ) . NT-pro-BNP levels were raised at baseline ( 595 ( SD 905 ) pg/ml ; range 5–4748 ) and fell in the irbesartan ( −124 ( SD 302 ) pg/ml , p = 0.01 ) and ramipril ( −173 ( SD 415 ) pg/ml , p = 0.03 ) groups only . Conclusions : In this typically elderly group of HF patients with normal LVEF , diuretic therapy significantly improved symptoms and neither irbesartan nor ramipril had a significant additional effect . However , diuretics in combination with irbesartan or ramipril marginally improved LV systolic and diastolic longitudinal LV function , and lowered NT-proBNP over 1 year BACKGROUND In patients who have vascular disease or high-risk diabetes without heart failure , angiotensin-converting-enzyme ( ACE ) inhibitors reduce mortality and morbidity from cardiovascular causes , but the role of angiotensin-receptor blockers ( ARBs ) in such patients is unknown . We compared the ACE inhibitor ramipril , the ARB telmisartan , and the combination of the two drugs in patients with vascular disease or high-risk diabetes . METHODS After a 3-week , single-blind run-in period , patients underwent double-blind r and omization , with 8576 assigned to receive 10 mg of ramipril per day , 8542 assigned to receive 80 mg of telmisartan per day , and 8502 assigned to receive both drugs ( combination therapy ) . The primary composite outcome was death from cardiovascular causes , myocardial infa rct ion , stroke , or hospitalization for heart failure . RESULTS Mean blood pressure was lower in both the telmisartan group ( a 0.9/0.6 mm Hg greater reduction ) and the combination-therapy group ( a 2.4/1.4 mm Hg greater reduction ) than in the ramipril group . At a median follow-up of 56 months , the primary outcome had occurred in 1412 patients in the ramipril group ( 16.5 % ) , as compared with 1423 patients in the telmisartan group ( 16.7 % ; relative risk , 1.01 ; 95 % confidence interval [ CI ] , 0.94 to 1.09 ) . As compared with the ramipril group , the telmisartan group had lower rates of cough ( 1.1 % vs. 4.2 % , P<0.001 ) and angioedema ( 0.1 % vs. 0.3 % , P=0.01 ) and a higher rate of hypotensive symptoms ( 2.6 % vs. 1.7 % , P<0.001 ) ; the rate of syncope was the same in the two groups ( 0.2 % ) . In the combination-therapy group , the primary outcome occurred in 1386 patients ( 16.3 % ; relative risk , 0.99 ; 95 % CI , 0.92 to 1.07 ) ; as compared with the ramipril group , there was an increased risk of hypotensive symptoms ( 4.8 % vs. 1.7 % , P<0.001 ) , syncope ( 0.3 % vs. 0.2 % , P=0.03 ) , and renal dysfunction ( 13.5 % vs. 10.2 % , P<0.001 ) . CONCLUSIONS Telmisartan was equivalent to ramipril in patients with vascular disease or high-risk diabetes and was associated with less angioedema . The combination of the two drugs was associated with more adverse events without an increase in benefit . ( Clinical Trials.gov number , NCT00153101 [ Clinical Trials.gov ] . ) We planned a r and omized , double blind clinical trial to evaluate whether an antihypertensive intervention at the proximal or distal level of the renin – angiotensin – aldosterone system could have different effects on a broad range of innovative cardiovascular risk biomarkers . A total of 288 hypertensive Caucasian patients ( 115 men and 113 women ) , aged ⩾18 years , were enrolled in this study . They were r and omized to take losartan 50 mg per day or ramipril 5 mg per day for 1 month and titrated up to 100 mg per day and 10 mg per day for 13 months , respectively . At baseline , 1 , 2 and 14 months after therapy initiation , we evaluated the following parameters : body weight , body mass index ( BMI ) , systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) , fasting plasma glucose ( FPG ) , M-value , adiponectin ( ADN ) , resistin ( r ) , retinol binding protein-4 ( RBP-4 ) , visfatin , vaspin , high-sensitivity C-reactive protein ( Hs-CRP ) , matrix metalloproteinase-2 ( MMP-2 ) and matrix metalloproteinase-9 ( MMP-9 ) . No variation of body weight , BMI , FPG or vaspin was obtained with either treatment . We recorded a similar improvement in SBP , DBP and Hs-CRP with both treatments ; however , losartan also increased M-value , ADN and visfatin , whereas ramipril did not . Furthermore , losartan decreased r , RBP-4 , MMP-2 and MMP-9 , whereas ramipril did not have any effect on these parameters . In conclusion , we observed that short-term treatment with losartan improved several metabolic parameters ( M-value , ADN , RBP-4 , r and visfatin ) and decreased vascular remodeling biomarkers ( MMP-2 and MMP-9 )  in hypertensive subjects , whereas ramipril did not Introduction P-wave dispersion ( PWD ) has been shown to be a non-invasive electrocardiographic predictor for development of atrial fibrillation ( AF ) . Thus , it may be possible to attenuate AF risk through improvement of PWD . In this study , we compared the effects of an angiotensin-converting enzyme ( ACE ) inhibitor , quinapril , and an angiotensin receptor blocker ( ARB ) , irbesartan , on PWD . Methods A total of 38 newly diagnosed hypertensive patients were enrolled in the study . The patients were r and omly assigned to receive treatment with either irbesartan ( 150–300 mg ) or quinapril ( 20–40 mg ) . P-wave duration s and PWD were measured at baseline and after 6 and 12 months of treatment . Echocardiographic examinations were performed at baseline and after 12 months of treatment . Results Both drugs significantly reduced blood pressure to a similar degree ( P<0.001 ) . Deceleration time ( both P<0.001 ) and isovolumetric relaxation time ( both P=0.007 ) were also significantly reduced , whereas there was no significant change in the early diastolic flow/atrial contraction signal ratio . Both irbesartan and quinapril significantly decreased maximum P-wave duration ( Pmax ) ( P<0.001 and P=0.002 , respectively ) and PWD ( from 68.0±22.1 to 41.0±25.1 msec for irbesartan , and from 70.5±20.4 to 46.6±13.3 msec for quinapril ; both P<0.001 ) . Baseline and follow-up blood pressure , heart rate , echocardiographic findings , and P-wave values were not significantly different between the irbesartan and quinapril groups . No patient developed AF during follow-up . There was no significant correlation between PWD and blood pressure or diastolic function parameters . Conclusion Antihypertensive treatment with either irbesartan or quinapril is associated with significant reductions in Pmax and PWD Persistence on treatment affects the efficacy of antihypertensive treatment . We prospect ively investigated the persistence on therapy and the extent of  blood pressure ( BP ) control  in 347 hypertensive patients ( age 59.4 ± 6 years ) r and omly allocated to a first-line treatment with : angiotensin-converting enzyme ( ACE ) inhibitors , calcium-channel blockers ( CCBs ) , ß-blockers , angiotensin-II receptor blockers ( ARBs ) , or diuretics and followed-up for 24-months . Persistence on treatment was higher in patients treated with ARBs ( 68.5 % ) and ACE inhibitors ( 64.5 % ) vs CCBs ( 51.6 % ; p < 0.05 ) , β-blockers ( 44.8 % , p < 0.05 ) , and diuretics ( 34.4 % , p < 0.01 ) . No ARB , ACE inhibitor , β-blocker , or diuretic was associated with a higher persistence in therapy compared with the other molecules used in each therapeutic class . The rate of persistence was significantly higher in patients treated with lercanidipine vs others CCBs ( 59.3 % vs 46.6 % , p < 0.05 ) . Systolic and diastolic BP was decreased more successfully in patients treated with ARBs ( −11.2/−5.8 mmHg ) , ACE inhibitors ( −10.5/−5.1 mmHg ) , and CCBs ( −8.5/−4.6 mmHg ) compared with ß-blockers ( −4.0/−2.3 mmHg p < 0.05 ) and diuretics ( −2.3/−2.1 mmHg , p < 0.05 ) . No ARB , ACE inhibitor , β-blocker , or diuretic was associated with a higher BP control compared with the other molecules used in each therapeutic class . A trend toward a better BP control was observed in response to lercanidipine vs other CCBs ( p = 0.059 ) . The present results confirm the importance of persistence on treatment for the management of hypertension in clinical practice BACKGROUND Angiotensin-converting enzyme ( ACE ) inhibitors reduce mortality , myocardial infa rct ion , stroke , heart failure , need for revascularization , nephropathy , and diabetes and its complications . Although angiotensin-II receptor blockers ( ARBs ) have been less extensively evaluated , theoretically they may have " protective " effects similar to those of ACE inhibitors , but with better tolerability . Currently , there is uncertainty about the role of ARBs when used alone or in combination with an ACE inhibitor in high-risk population s with controlled hypertension . OBJECTIVES Primary objectives of the ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial ( ONTARGET ) are to determine if the combination of the ARB telmisartan and the ACE inhibitor ramipril is more effective than ramipril alone , and if telmisartan is at least as effective as ramipril . The Telmisartan R and omized AssessmeNt Study in aCE iNtolerant subjects with cardiovascular Disease ( TRANSCEND ) will determine if telmisartan is superior to placebo in patients who are intolerant of ACE inhibitors . The primary outcome for both trials is the composite of cardiovascular death , myocardial infa rct ion , stroke , or hospitalization for heart failure . METHOD High-risk patients with coronary , peripheral , or cerebrovascular disease or diabetes with end-organ damage are being recruited and followed for 3.5 to 5.5 years in 2 parallel , r and omized , double-blind clinical trials . PROGRESS Recruitment from 730 centers in 40 countries for ONTARGET ( n = 25,620 ) was completed in July 2003 . For TRANSCEND , 5776 patients ( out of a projected total of 6000 ) have been recruited ( by May 10 , 2004 ) . Baseline patient characteristics are comparable to the Heart Outcomes Prevention Evaluation ( HOPE ) trial , the basis of the design of the current study , confirming that patients are at high-risk Structural alterations of subcutaneous small resistance arteries are associated with a worse clinical prognosis in hypertension and noninsulin-dependent diabetes mellitus ( NIDDM ) . However , no data are presently available about the effects of antihypertensive therapy on vascular structure in hypertensive patients with NIDDM . Therefore , we have investigated the effect of an angiotensin-converting enzyme inhibitor , enalapril , and a highly selective angiotensin receptor blocker , c and esartan cilexetil , on indices of subcutaneous small resistance artery structure in 15 patients with mild hypertension and NIDDM . Eight patients were treated with c and esartan ( 8 to 16 mg per day ) and 7 with enalapril ( 10 to 20 mg per day ) for 1 year . Each patient underwent a biopsy of the subcutaneous fat from the gluteal region at baseline and after 1 year of treatment . Small arteries were dissected and mounted on a micromyograph and the media-to-internal lumen ratio was evaluated ; moreover , endothelium-dependent vasodilation to acetylcholine was assessed . A similar blood pressure-lowering effect and a similar reduction of the media-to-lumen ratio of small arteries was observed with the 2 drugs . Vascular collagen content was reduced and metalloproteinase-9 was increased by c and esartan , but not by enalapril . Changes of circulating indices of collagen turnover and circulating matrix metalloproteinase paralleled those of vascular collagen . The 2 drugs equally improved endothelial function . In conclusion , antihypertensive treatment with drugs that inhibit the renin-angiotensin-aldosterone system activity is able to correct , at least in part , alterations in small resistance artery structure in hypertensive patients with NIDDM .  C and esartan may be more effective than enalapril in reducing collagen content in the vasculature We investigated the effects of aggressive antihypertensive therapy based on hydrochlorothiazide , c and esartan or lisinopril on urinary albumin excretion , endothelial function and inflammatory activity in hypertensive type II diabetic individuals . A total of 70 hypertensive type II diabetic individuals were treated with three antihypertensive strategies in a r and omized , double-blind , double-dummy design . Blood pressure was titrated to levels below 130/85 mmHg or a decrease in systolic pressure of 10 % with a diastolic pressure below 85 mmHg . After titration , patients were treated for 12 months . Mean blood pressures changed from 157/93 , 151/94 and 149/93 at baseline to 135/80 , 135/82 and 131/80 mmHg after titration in the hydrochlorothiazide ( n=24 ) , c and esartan ( n=24 ) and lisinopril ( n=22 ) groups . About 70 % reached target blood pressures . However , only 45 % had blood pressures < 130/85 mmHg . Urinary albumin excretion and levels of soluble vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 decreased ( GEE regression coefficients , −2.40 mg/24 h ( P<0.001 ) , −85 ng/ml ( P=0.01 ) and −50 ng/ml ( P=0.02 ) ) , but brachial artery endothelium-dependent and -independent vasodilation and levels of von Willebr and factor and C-reactive protein did not change ( GEE regression coefficients , 0.21 mm ( P=0.07 ) , 0.04 mm ( P=0.43 ) , 0.04 IU/ml ( P=0.33 ) and −1.15 mg/l ( P=0.64 ) ) . No differences in outcome variables between treatment groups were observed . These data show that achievement of target blood pressures below 130/85 mmHg in hypertensive type II diabetes is difficult . Aggressive antihypertensive therapy can improve urinary albumin excretion , endothelial function and inflammatory activity in hypertensive type II diabetic individuals , regardless of the type of antihypertensive therapy used The Renoprotection of Optimal Antiproteinuric Doses ( ROAD ) study was performed to determine whether titration of benazepril or losartan to optimal antiproteinuric doses would safely improve the renal outcome in chronic renal insufficiency . A total of 360 patients who did not have diabetes and had proteinuria and chronic renal insufficiency were r and omly assigned to four groups . Patients received open-label treatment with a conventional dosage of benazepril ( 10 mg/d ) , individual uptitration of benazepril ( median 20 mg/d ; range 10 to 40 ) , a conventional dosage of losartan ( 50 mg/d ) , or individual uptitration of losartan ( median 100 mg/d ; range 50 to 200 ) . Uptitration was performed to optimal antiproteinuric and tolerated dosages , and then these dosages were maintained . Median follow-up was 3.7 yr . The primary end point was time to the composite of a doubling of the serum creatinine , ESRD , or death . Secondary end points included changes in the level of proteinuria and the rate of progression of renal disease . Compared with the conventional dosages , optimal antiproteinuric dosages of benazepril and losartan that were achieved through uptitration were associated with a 51 and 53 % reduction in the risk for the primary end point ( P = 0.028 and 0.022 , respectively ) . Optimal antiproteinuric dosages of benazepril and losartan , at comparable BP control , achieved a greater reduction in both proteinuria and the rate of decline in renal function compared with their conventional dosages . There was no significant difference for the overall incidence of major adverse events between groups that were given conventional and optimal dosages in both arms . It is concluded that uptitration of benazepril or losartan against proteinuria conferred further benefit on renal outcome in patients who did not have diabetes and had proteinuria and renal insufficiency OBJECTIVES The goal of this study was to compare myocardial perfusion reserve ( MPR ) before and after long-term treatment with lisinopril and losartan in patients with hypertension and left ventricular hypertrophy ( LVH ) . BACKGROUND Studies have suggested that treatment with angiotensin-converting enzyme inhibitors ( ACEIs ) improves MPR in patients with hypertension by potentiating endogenous bradykinins . Because angiotensin receptor blockers ( ARBs ) lack a direct effect on bradykinins , we hypothesized that they may not improve MPR . METHODS We measured pre- and post-treatment myocardial blood flow ( MBF ) by positron emission tomography in 17 patients ( lisinopril : 9 patients , losartan : 8 patients ) with hypertension and LVH at baseline and after coronary vasodilation with intravenous dipyridamole .  In addition , we measured rest and hyperemic blood flow in eight normotensive controls . RESULTS Post-treatment maximal coronary blood flow and MPR in the lisinopril group increased significantly compared with pretreatment values ( 3.5 + /- 1.2 vs. 2.6 + /- 1.1 ml/min/g , p = 0.02 ; 3.7 + /- 1.1 vs. 2.4 + /- 1 ml/min/g , respectively , p = 0.002 , respectively ) . Post-treatment hyperemic flow in the patients treated with lisinopril was not significantly different from corresponding measurements in controls ( 3.5 + /- 1.2 vs. 3.9 + /- 1 ml/min/g , respectively , p = NS ) . In the patients treated with losartan , there was no difference between pre- and post-treatment MBF values and MPR . CONCLUSIONS Myocardial perfusion reserve and maximal coronary flow improved in asymptomatic patients with hypertension-induced LVH after long-term treatment with lisinopril but not with losartan . Thus , ACEIs , but not ARBs , might be effective in repairing the coronary microangiopathy associated with hypertension-induced LVH A total of 501 elderly patients with essential hypertension were r and omized to receive  valsartan or lisinopril in this one year multi-center , double-blind , parallel group trial . Patients received valsartan 40 mg ( n = 334 ) or lisinopril 2.5 mg ( n = 167 ) daily for 2 weeks with subsequent titration ( alone or in combination with hydroclorothiazide ) , depending on response to treatment . The primary efficacy variable was the percentage of patients with a response , defined as sitting diastolic blood pressure < 90 mmHg or drop of > or = 10 mmHg from baseline . A high percentage of patients responded to treatment in both valsartan and lisinopril groups : 80 % for both groups at 12 weeks and 81 % and 87 % , respectively , at 52 weeks with no statistically significant difference between treatments ( 12 weeks , p = 0.925 ; 52 weeks , p = 0.148 ) . More patients on lisinopril experienced drug-related cough ( 7.5 % on valsartan , 17.4 % on lisinopril ) . In 5.4 % of lisinopril treated patients , cough led to discontinuation of therapy compared to 0.6 % on valsartan . Valsartan 80 mg daily provides comparable short and long-term antihypertensive efficacy to lisinopril in elderly patients with a lower incidence of drug-related cough Abstract We compared the efficacy of treatment protocol s with an angiotensin converting enzyme ( ACE ) inhibitor alone ( enalapril , 5 mg ) or angiotensin II ( ATII ) receptor blocker ( losartan , 50 mg ) or both enalapril plus losartan in patients with microalbuminuria in a prospect i ve , r and omized clinical trial . Normotensive type 2 diabetic patients with microalbuminuria documented by at least 3 consecutive urinary albumin excretion analyses were recruited for the study . Patients were grouped r and omly into one of the protocol s which consisted of treatment with 5 mg enalapril daily ( group 1 ; n=12 ) , 50 losartan daily ( group 2 ; n=12 ) or both drugs ( group 3 ; n=10 ) . They were reevaluated with regard to HbA1c levels , lipid profiles , blood pressure and urinary albumin excretion rates ( UAER ) at 3-month intervals for 12 months . Mean age , duration of diabetes , body mass index , plasma lipid profiles and blood pressure levels were similar at the initial visit . In group 1 , UAER returned to normal levels in 10 patients . Normalization of UAER occurred in 8 and 7 patients in groups 2 and 3 , respectively . Percentage of reduction in UAERs at the end of 12 months were 58 % , 59 % and 60 % ( p=0.0001 ; p=0.0002 ; p=0.0003 , respectively ) . The amount of reduction in UAER did not differ significantly among the three groups ( p=0.346 ) . ACE inhibitors and angiotensin II receptor blockers have similar efficacy in treating diabetic microalbuminuria , and the combination of the two drugs does not add any further benefit BACKGROUND ACE inhibitors attenuate the detrimental effects of angiotensin II , and improve survival and reduce morbidity in patients with acute myocardial infa rct ion and evidence of heart failure or left-ventricular dysfunction . Selective antagonism of the angiotensin type 1 receptor represents an alternative approach to inhibition of the renin-angiotensin system . We did a multicentre , r and omised trial to test the hypothesis that the angiotensin II antagonist losartan would be superior or non-inferior to the ACE inhibitor captopril in decreasing all-cause mortality in high-risk patients after acute myocardial infa rct ion . METHODS 5477 patients 50 years of age or older ( mean age 67.4 years [ SD 9.8 ] ) , with confirmed acute myocardial infa rct ion and heart failure during the acute phase or a new Q-wave anterior infa rct ion or reinfa rct ion , were recruited from 329 centres in seven European countries . Patients were r and omly assigned and titrated to a target dose of losartan ( 50 mg once daily ) or captopril ( 50 mg three times daily ) as tolerated . The primary endpoint was all-cause mortality . Analysis was by intention to treat . FINDINGS There were 946 deaths during a mean follow-up of 2.7 ( 0.9 ) years : 499 ( 18 % ) in the losartan group and 447 ( 16 % ) in the captopril group ( relative risk 1.13 [ 95 % CI 0.99 - 1.28 ] , p=0.07 ) . The results for the secondary and tertiary endpoints were as follows : sudden cardiac death or resuscitated cardiac arrest 239 ( 9 % ) versus 203 ( 7 % ) , 1.19 ( 0.98 - 1.43 ) , p=0.07 , and fatal or non-fatal reinfa rct ion 384 ( 14 % ) versus 379 ( 14 % ) , 1.03 ( 0.89 - 1.18 ) , p=0.72 . The all-cause hospital admission rates were 1806 ( 66 % ) versus 1774 ( 65 % ) , 1.03 ( 0.97 - 1.10 ) , p=0.37 . Losartan was significantly better tolerated than captopril , with fewer patients discontinuing study medication ( 458 [ 17 % ] vs 624 [ 23 % ] , 0.70 [ 0.62 - 0.79 ] , p<0.0001 ) . INTERPRETATION Since we saw a non-significant difference in total mortality in favour of captopril , ACE inhibitors should remain first-choice treatment in patients after complicated acute myocardial infa rct ion .  Losartan can not be generally recommended in this population . However , it was better tolerated than captopril , and was associated with significantly fewer discontinuations . Although the role of losartan in patients intolerant of ACE inhibition is not clearly defined , it can be considered in such patients In this study , telmisartan , a new angiotensin AT ( 1 ) receptor antagonist given as monotherapy and in combination with hydrochlorothiazide ( HCTZ ) , was compared with lisinopril as monotherapy and in combination with HCTZ . This 52-week , r and omized , multicenter , double-blind , double-dummy , parallel-group , dose-titration study of 578 patients with mild-to-moderate essential hypertension ( mean diastolic blood pressure [ DBP ] , > /=95 mm Hg ) , compared the efficacy and safety of telmisartan ( n = 385 ) with lisinopril ( n = 193 ) . Dosage could be increased for both telmisartan ( 40 -- > 80 -- > 160 mg ) and lisinopril ( 10 -- > 20 -- > 40 mg ) at each of the first 2 monthly visits if DBP control ( < 90 mm Hg ) had not been established . Once DBP control was established , patients entered the 48-week maintenance period . During this period , the dose of the study drug was fixed , although open-label HCTZ at 12.5 mg or 25 mg was added , when needed , to regain DBP control . At the end of the titration period , DBP control was achieved on monotherapy by 67 % and 63 % of the telmisartan and lisinopril patients , respectively . At the end of the maintenance period , supine DBP was controlled in 83 % and 87 % of the telmisartan and lisinopril patients , respectively , with systolic blood pressure over DBP reductions of 23.8/16.6 mm Hg for telmisartan and 19.9/15.6 mm Hg for lisinopril .  Treatment-related side effects occurred in fewer telmisartan-treated patients ( 28 % ) than in lisinopril-treated patients ( 40 % ; P = .001 ) . Significantly fewer patients ( P = .018 ) receiving telmisartan experienced treatment-related cough ( 3 % v 7 % ) , and cough led to discontinuation significantly less often ( P = .007 ) with telmisartan treatment than with lisinopril treatment ( 0.3 % v 3.1 % ) . In addition , two cases of angioedema were observed , both in the lisinopril group . The selective AT ( 1 ) receptor antagonist , telmisartan , is extremely effective in the treatment of mild-to-moderate hypertension both as monotherapy and in combination with HCTZ and is at least comparable in efficacy to lisinopril , with a tolerability profile that may offer advantages in terms of a reduced incidence of adverse events BACKGROUND Present angiotensin-converting-enzyme inhibitor treatment fails to prevent progression of non-diabetic renal disease . We aim ed to assess the efficacy and safety of combined treatment of angiotensin-converting-enzyme inhibitor and angiotensin-II receptor blocker , and monotherapy of each drug at its maximum dose , in patients with non-diabetic renal disease . METHODS 336 patients with non-diabetic renal disease were enrolled from one renal outpatient department in Japan . After screening and an 18-week run-in period , 263 patients were r and omly assigned angiotensin-II receptor blocker ( losartan , 100 mg daily ) , angiotensin-converting-enzyme inhibitor ( tr and olapril , 3 mg daily ) , or a combination of both drugs at equivalent doses .  Survival analysis was done to compare the effects of each regimen on the combined primary endpoint of time to doubling of serum creatinine concentration or end-stage renal disease . Analysis was by intention to treat . FINDINGS Seven patients discontinued or were otherwise lost to follow-up . Ten ( 11 % ) of 85 patients on combination treatment reached the combined primary endpoint compared with 20 ( 23 % ) of 85 on tr and olapril alone ( hazard ratio 0.38 , 95 % CI 0.18 - 0.63 , p=0.018 ) and 20 ( 23 % ) of 86 on losartan alone ( 0.40 , 0.17 - 0.69 , p=0.016 ) . Covariates affecting renal survival were combination treatment ( hazard ratio 0.38 , 95 % CI 0.18 - 0.63 , p=0.011 ) , age ( 1.30 , 1.03 - 2.29 , p=0.009 ) , baseline renal function ( 1.80 , 1.02 - 2.99 , p=0.021 ) , change in daily urinary protein excretion rate ( 0.58 , 0.24 - 0.88 , p=0.022 ) , use of diuretics ( 0.80 , 0.30 - 0.94 , p=0.043 ) , and antiproteinuric response to tr and olapril ( 0.81 , 0.21 - 0.91 , p=0.039 ) . Frequency of side-effects with combination treatment was the same as with tr and olapril alone . INTERPRETATION Combination treatment safely retards progression of non-diabetic renal disease compared with monotherapy . However , since some patients reached the combined primary endpoint on combined treatment , further strategies for complete management of progressive non-diabetic renal disease need to be research ed BACKGROUND The objectives of this study were to compare the effects of the angiotensin II receptor blocker , losartan , to those of the angiotensin-converting enzyme inhibitor , enalapril , on albuminuria and renal function in relationship to clinic and ambulatory blood pressure ( ABP ) in hypertensive type 2 diabetic subjects with early nephropathy . The tolerability of these agents and their effect on the metabolic profile were also evaluated . METHODS The study was a one-year prospect i ve , double-blind trial with losartan and enalapril administered alone or in combination with hydrochlorothiazide and other antihypertensive agents .  ABP and renal and biochemical parameters were measured at baseline and after 12 , 28 , and 52 weeks of active treatment . Ninety-two hypertensive type 2 diabetics with early nephropathy completed the study . RESULTS Both losartan and enalapril administered alone or in combination with other agents induced significant reductions in sitting clinic ( P < 0.05 ) and ABP ( P < 0.002 ) without a statistical difference between groups . Geometric means for urinary albumin excretion ( UAE ) decreased significantly ( P < 0.001 ) in patients treated with losartan from 64 . 1 to 41.5 microg/min and in those treated with enalapril from 73.9 to 33.5 microg/min after 52 weeks of therapy . A significant relationship ( P < 0.05 ) between changes in systolic and diastolic ABP and the decrease in UAE at 52 weeks was seen in both groups . The decline in glomerular filtration rate ( GFR ) was stabilized at the end of therapy and was identical in both treatment groups . Treatment with enalapril was associated with a significantly higher incidence of cough ( P = 0.006 ) and a rise in serum uric acid ( P = 0.002 ) compared with losartan . CONCLUSIONS Our results indicate that a one-year course of antihypertensive therapy with either losartan or enalapril significantly reduces UAE in hypertensive type 2 diabetic patients with early nephropathy . The reduction in UAE with each treatment is similarly related to decrements in ABP . In addition , the rate of decline in GFR is similar in both treatment groups BACKGROUND Angiotensin-converting-enzyme ( ACE ) inhibitors such as captopril reduce mortality and cardiovascular morbidity among patients with myocardial infa rct ion complicated by left ventricular systolic dysfunction , heart failure , or both . In a double-blind trial , we compared the effect of the angiotensin-receptor blocker valsartan , the ACE inhibitor captopril , and the combination of the two on mortality in this population of patients . METHODS Patients receiving conventional therapy were r and omly assigned , 0.5 to 10 days after acute myocardial infa rct ion , to additional therapy with valsartan ( 4909 patients ) , valsartan plus captopril ( 4885 patients ) , or captopril ( 4909 patients ) . The primary end point was death from any cause . RESULTS During a median follow-up of 24.7 months , 979 patients in the valsartan group  died , as did 941 patients in the valsartan- and -captopril group and 958 patients in the captopril group ( hazard ratio in the valsartan group as compared with the captopril group , 1.00 ; 97.5 percent confidence interval , 0.90 to 1.11 ; P=0.98 ; hazard ratio in the valsartan- and -captopril group as compared with the captopril group , 0.98 ; 97.5 percent confidence interval , 0.89 to 1.09 ; P=0.73 ) . The upper limit of the one-sided 97.5 percent confidence interval for the comparison of the valsartan group with the captopril group was within the prespecified margin for noninferiority with regard to mortality ( P=0.004 ) and with regard to the composite end point of fatal and nonfatal cardiovascular events ( P<0.001 ) . The valsartan- and -captopril group had the most drug-related adverse events . With monotherapy , hypotension and renal dysfunction were more common in the valsartan group , and cough , rash , and taste disturbance were more common in the captopril group . CONCLUSIONS Valsartan is as effective as captopril in patients who are at high risk for cardiovascular events after myocardial infa rct ion . Combining valsartan with captopril increased the rate of adverse events without improving survival We investigated the effects of aggressive antihypertensive therapy based on hydrochlorothiazide , c and esartan or lisinopril on left ventricular mass ( LVM ) index and arterial stiffness in hypertensive type II diabetic individuals . Seventy hypertensive type II diabetic individuals were treated with three antihypertensive strategies in a r and omized , double-blind , double-dummy design . Blood pressure was titrated to levels below 130/85 mm Hg or a decrease in systolic pressure of 10 % with a diastolic pressure below 85 mm Hg . After titration , patients were treated for 12 months . Mean blood pressures were 157/93 , 151/94 and 149/93 mm Hg at baseline in the hydrochlorothiazide ( n=24 ) , c and esartan ( n=24 ) and lisinopril ( n=22 ) groups , and 135/80 , 135/82 and 131/80 mm Hg after titration . About 70 % reached target blood pressures , with the median use of three antihypertensive drugs . Left ventricular mass index and all estimates of arterial stiffness showed significant improvement after 12 months : that is , LVM index ( −11 g/m2 ; −8 % ) ; carotid distensibility coefficient ( DC ; + 2.8 × 10−3 kPa−1 ; + 27 % ) , compliance coefficient ( CC ; + 0.13 mm2/kPa ; + 21 % ) and elastic modulus ( −0.19 kPa ; −16 % ) ; femoral DC ( + 1.6 × 10−3 kPa−1 ; + 50 % ) and CC ( + 0.08 mm2/kPa ; + 26 % ) ; brachial DC ( + 2.1 × 10−3 kPa−1 ; + 39 % ) and CC ( + 0.03 mm2/kPa ; + 27 % ) and total systemic arterial compliance ( + 0.29 ml/mm Hg ; + 16 % ) . No differences in outcome variables between treatment groups were observed . Aggressive antihypertensive treatment , although difficult to achieve , result ed in substantial reductions of LVM index and arterial stiffness in relatively uncomplicated hypertensive type II diabetic individuals . Strategies based on renin – angiotensin system inhibitors were not clearly superior to conventional ( i.e. diuretic-based ) strategies Objective : The objective of this study was to compare valsartan or ramipril addition to amlodipine + hydrochlorothiazide ( HCTZ ) on blood pressure ( BP ) and left ventricular hypertrophy ( LVH ) in hypertensive diabetic patients with LVH . Research design and methods : 293 patients were treated with  amlodipine 10 mg + HCTZ 12.5 combination and then r and omized to receive valsartan 160 mg or ramipril 5 mg , in addition to the previous therapy , for 1 year . Main outcome measures : Clinic BP was measured every month ; echocardiographic assessment s were performed at the end of the placebo period , both before the r and omization and after 1-year of triple combination therapy . Results : Both triple regimens similarly reduced SBP/DBP values ( -13.5/10.9 mm Hg in the valsartan group and -13.4/10.4 mm Hg in the ramipril group ) . Triple combination including valsartan better reduced LVMI ( -20.1 % , p < 0.001 ) , interventricular septal thickness ( IVST ) ( -20.3 % , p < 0.001 ) and left ventricular posterior wall thickness ( PWT ) ( -16.3 % , p < 0.001 ) , compared with triple combination including ramipril ( -14 % , p < 0.01 ; -16.2 % , p < 0.001 and -9 % , p < 0.01 , respectively ) ; the difference between treatments being statistically significant ( p < 0.05 ) . Triple combination with valsartan gave a greater increase of E/A ratio ( p < 0.05 between groups ) . Conclusions : Valsartan addition to dual therapy with amlodipine + HCTZ was more effective than ramipril addition in reducing LVH OBJECTIVE To investigate the effect of angiotensin converting enzyme inhibition ( ACE-I ) or angiotensin receptor blockade ( ARB ) , and their combination , on both diabetic autonomic neuropathy ( DAN ) and left ventricular ( LV ) diastolic dysfunction ( LVDD ) in asymptomatic patients with diabetes mellitus ( DM ) . MATERIAL S AND METHODS Sixty-two patients ( 34 women ) with long-term DM ( 24 with Type 1 ) and DAN , aged 51.7+/-13.9 years , free of coronary artery disease ( CAD ) or arterial hypertension ( HT ) at baseline , were studied for a 12-month period . Diagnosis of DAN was established if two or more of the st and ard cardiovascular reflex tests ( CRT ) were abnormal . Patients were r and omly allocated to quinapril ( 20 mg/day ) , losartan ( 100 mg/day ) , or quinapril plus losartan ( 20 mg/day+100 mg/day ) . LV systolic and diastolic function was assessed using radionuclide ventriculography ( RNV ) at baseline and after 12 months of treatment . RESULTS In all three treatment groups , abnormal CRT values were improved . In the quinapril group , the first third filling fraction ( 1/3FF , 48.9+/-17.8 % vs. 39.2+/-12.9 % at baseline , P=.005 ) was increased and the atrial contribution to ventricular filling ( 25.1+/-6.3 vs. 30.1+/-7.8 , P=.027 ) was reduced in the losartan group ; the peak filling rate ( PFR ) was improved ( 3.41+/-.62 vs. 3.11+/-.44 volumes/s , P=.05 ) , and in the combination group , the 1/3FF ( 39.4+/-11.8 % vs. 29.6+/-11.9 % , P=.018 ) was markedly increased , while the time to peak filling ( TPF ; 147+/-42 vs. 184+/-33 ms , P=.02 ) and the TPF/filling time ( TPF/FT ; 32.5+/-6.2 % vs. 38.2+/-5.7 % , P=.016 ) were reduced . CONCLUSIONS Early ACE-I or ARB improve both DAN and LVDD in asymptomatic patients with Type 1 or 2 DM , after 1 year of treatment . Their combination may be slightly better than monotherapies on DAN and LVDD . The clinical importance of these effects should be vali date d by larger studies BACKGROUND Blocking the renin-angiotensin system ( RAS ) with angiotensin receptor blockers or angiotensin-converting enzyme inhibitors protects against renal injury in patients with chronic kidney disease ( CKD ) . The aim of this study was to compare the chronic effects of telmisartan and enalapril on proteinuria , urinary liver-type fatty acid-binding protein ( L-FABP ) and endothelin (ET)-1 levels in patients with mild CKD . MATERIAL S AND METHODS Thirty CKD patients with mild to moderate renal insufficiency ( 20 men and 10 women ; mean age , 37 years ; estimated glomerular filtration rate ( eGFR ) > 60 mL min(-1 ) and blood pressure > 130/85 mmHg ) were included in the study . Patients were r and omly assigned to receive telmisartan at 80 mg day(-1 ) ( n = 15 ) or enalapril at 10 mg day(-1 ) ( n = 15 ) . We measured blood pressure , serum creatinine , eGFR , urinary protein , L-FABP and ET-1 before the start of treatment and 6 and 12 months after the start of treatment . RESULTS The blood pressure reduction rate was similar between the two groups . Urinary protein , L-FABP and ET-1 levels were significantly reduced in both groups 6 and 12 months ( P < 0.001 ) after treatment , but the reduction rates were more pronounced in patients receiving telmisartan than in those receiving enalapril ( P < 0.001 ) . Estimated glomerular filtration rate was increased similarly in both groups at 12 months . CONCLUSIONS The study results suggest that telmisartan results in a greater reduction of urinary markers than does enalapril and that this effect occurs by a mechanism independent of blood pressure reduction . It would be needed to investigate whether the differences may be distinct or not the same when other dosages are used BACKGROUND Hemodialysis patients have uremic dyslipidemia , represented by elevated serum intermediate-density lipoprotein cholesterol ( IDL-C ) levels , and an increased cardiovascular mortality rate . This study was performed to determine the low-dose effects of the angiotensin II receptor blocker losartan and the angiotensin-converting enzyme inhibitor tr and olapril on pulse wave velocity ( PWV ) , which predicts cardiovascular morbidity and mortality in hemodialysis patients . METHODS Serum lipid levels and PWV were monitored for 12 months in 64 hemodialysis patients who were administered low doses of losartan or tr and olapril or a placebo .  RESULTS At the start of the study , there were no differences in patient characteristics among the 3 groups . PWV tended to increase in the placebo group during the 12-month study period , but decreased significantly in the losartan and tr and olapril groups , and decreases in PWV were similar in the losartan and tr and olapril groups . There were no changes in blood pressure , hematocrit , erythropoietin dose , ankle-brachial index , serum lipid levels , serum 8-isoprostane levels , or serum C-reactive protein levels during the 12-month study period , but there was an increase in serum triglyceride levels in the losartan group and a decrease in serum IDL-C levels in the losartan and tr and olapril groups . CONCLUSION In hemodialysis patients , tr and olapril is as effective as losartan in decreasing PWV independent of its depressor effect and in suppressing elevated IDL-C levels . Long-term blockade of the renin-angiotensin system may have a beneficial effect on the acceleration of atherosclerosis and uremic dyslipidemia Left ventricular hypertrophy ( LVH ) is frequently found at the initiation of dialysis therapy of diabetic and hypertensive patients , and is highly predictive of future cardiac morbidity and mortality . In patients with hypertension and LVH , both an angiotensin converting enzyme ( ACE ) inhibitor and an angiotensin type 1 receptor ( AT1 ) antagonist regress LVH . However , it remains controversial whether dual blockade of the renin-angiotensin system will regress LVH in these patients using a combination of ACE inhibitor and AT1 antagonist . Thirty-three type II diabetic patients with end-stage renal disease who had just entered into hemodialysis therapy and were diagnosed as having LVH evaluated by echocardiography were selected from three dialysis units staffed by the faculty of Saitama Medical School , Saitama , Japan between 1999 and 2001 . The study was carried out for 1 year . All patients were assigned r and omly to three groups with equal number : group I , an ACE inhibitor , enalapril 10 mg daily ; group II , an AT1 antagonist , losartan 100 mg daily ; group III , combination of enalapril 10 mg and losartan 100 mg daily . All antihypertensive drugs were given 30 min after the cessation of dialysis therapy .  LVH was evaluated by echocardiography before the start of administration of drugs , at 6 months and 12 months after the start of drug therapy . Systolic blood pressure levels less than 140 mmHg were the target for the three groups . Using repeated measures analysis of variance , applied to those with four echocardiograms , there were progressive decreases over time in left ventricular mass index , posterior wall thickness and interventricular septum thickness . There were no significant differences in regression of LVH as well as blood pressure control between enalapril and losartan groups ; however , dual blockade induced an additional 28 % reduction in left ventricular mass index compared with any type of monotherapy . Both ACE inhibitors and AT1 antagonists benefit the regression of LVH in diabetic patients who start dialysis therapy . Moreover , combination therapy with ACE inhibitors and AT1 antagonists would provide more beneficial effects on LVH in these patients than monotherapy BACKGROUND The ELITE study showed an association between the angiotensin II antagonist losartan and an unexpected survival benefit in elderly heart-failure patients , compared with captopril , an angiotensin-converting-enzyme ( ACE ) inhibitor . We did the ELITE II Losartan Heart Failure Survival Study to confirm whether losartan is superior to captopril in improving survival and is better tolerated . METHODS We undertook a double-blind , r and omised , controlled trial of 3,152 patients aged 60 years or older with New York Heart Association class II-IV heart failure and ejection fraction of 40 % or less . Patients , stratified for beta-blocker use , were r and omly assigned losartan ( n=1,578 ) titrated to 50 mg once daily or captopril ( n=1,574 ) titrated to 50 mg three times daily . The primary and secondary endpoints were all-cause mortality , and sudden death or resuscitated arrest . We assessed safety and tolerability . Analysis was by intention to treat . FINDINGS Median follow-up was 555 days . There were no significant differences in all-cause mortality ( 11.7 vs 10.4 % average annual mortality rate ) or sudden death or resuscitated arrests ( 9.0 vs 7.3 % ) between the two treatment groups ( hazard ratios 1.13 [ 95.7 % CI 0.95 - 1.35 ] , p=0.16 and 1.25 [ 95 % CI 0.98 - 1.60 ] , p=0.08 ) . Significantly fewer patients in the losartan group ( excluding those who died ) discontinued study treatment because of adverse effects ( 9.7 vs 14.7 % , p<0.001 ) , including cough ( 0.3 vs 2.7 % ) Background : Hypertension is frequently seen in autosomal dominant polycystic kidney disease ( ADPKD ) , and it has a negative effect on renal progression . Hypertension and left ventricle hypertrophy ( LVH ) are related in terms of pathogenesis and their effects on renal progression . In this study , we aim ed to compare the effects of losartan and ramipril on blood pressure ( BP ) control , LVH , and renal progression in patients with hypertensive ADPKD . Methods : Thirty-two ADPKD patients with ages ranging between 18 and 70 years who were stage 1–2 hypertensive were included in this study . Routine biochemical tests and echocardiography were obtained at first examination of the patients . Following these , the patients were r and omized . One group was given losartan and the other ramipril . They were followed up for 1 year , and their echocardiographies and routine biochemical tests were repeated at the end of the year . Results : BP values decreased in both the groups at the end of the first year ( p < 0.001 ) . There was a statistically significant difference in LVH in both the groups at the end of the first year than at the beginning ( losartan , p = 0.007 ; ramipril , p < 0.001 ) . Conclusions : In this study , effective BP control was obtained with losartan and ramipril and LVH was found to be regressed significantly in the hypertensive patients with ADPKD . These two groups of antihypertensive drugs may also have beneficial effects on the retardation of renal progression and in reducing cardiovascular mortality in hypertensive patients with ADPKD
target: Our analyses found no evidence of a difference in total mortality or cardiovascular outcomes for ARBs as compared with ACE inhibitors , while ARBs caused slightly fewer WDAEs than ACE inhibitors .
  Although ACE inhibitors have shown efficacy in these outcomes over placebo , our results can not be used to extrapolate the same conclusion for ARBs directly , which have not been studied in placebo-controlled trials for hypertension .
background: BACKGROUND Angiotensin converting enzyme inhibitors ( ACE inhibitors ) and angiotensin receptor blockers ( ARBs ) are widely prescribed for primary hypertension ( systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg ) .
  However , while ACE inhibitors have been shown to reduce mortality and morbidity in placebo-controlled trials , ARBs have not .
  Therefore , a comparison of the efficacies of these two drug classes in primary hypertension for preventing total mortality and cardiovascular events is important .
  OBJECTIVES To compare the effects of ACE inhibitors and ARBs on total mortality and cardiovascular events , and their rates of withdrawals due to adverse effects ( WDAEs ) , in people with primary hypertension .