Friday, July 09, 2010


It would appear that this decade could see an greater medical emphasis on diabetes and hypertension, and in particular, indentifying risk markers, in an attempt to target our therapy. The recently concluded European Society of Hypertension, European Meeting on Hypertension 2010 featured another paper presented by Dr Roland Schmeiger of the University of Elngen, Germany, on a subgroup analysis on " On-Target ". On-Target is a very large ( 27,000 patients ) clinical trial carried out by Boerhinger-Ingelheim to compare the BP lowering effects of Telmisartan ( an ARB ) against Ramipril ( an ACE-I ), and Telmisartan + Ramipril comination. As we now know ( the results were annonced last year ), Telmisartan was not inferior to Ramipril and Ramipril + Telmisartan did not confer any additional benefit and does carry an incease incidence of adverse reactions.
Well, Dr Schmeiger and colleagues looked into those patients with hypertension who also had albuminuria. There were about 23,000 in total. They found that albuminuria was an important CV risk marker. When albuminuria increase over 32 months, the CV risk increase and mortality increase by almost 50% should albuminuria increase by 2 folds during follow-up. Fortunately, when albuminuria reduce by half, the CV risk and all cause mortality also reduced by half.
This analysis clearly shows that monitoring of albuminuria, in patients whilst on treatment with an ACE-I or ARB is important as it is an important risk marker. Less albuminuria means less longterm problem and more albuminuria means more longterm problem Surfice to say that monitoring albuminuria is relatively cheap and should be done at least 6 monthly.
However, I think that more work needs to be done. The data on prolong ACE-I and ARB therapy ( greater then 3 years ) on albuminuria and micro-albuminuria, is still lagging. Will these effects last greater then 3 years? Do we have enough data?
The other very interesting point which I am beginning to understand is the role of statins? Does statin therapy, enhance and prolong the good effects of ACE-I and ARB, on albuminuria? There is some evidence to say so.
Looks like all these work is paving the way for combo pills of the future.
However, I still maintain that the best answer to chronic cardiovascular disease is prevention through aggressive life style modification. If only the Ministy of Health will limit the amount of sugar and salt in our food. That will surely go a long way, at no great cost, except perhaps the cost of self discipline.

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