New definitions in cardiovascular risk management: is it time for angiotensin II receptor blockers to become first-line medication?

The risk for coronary heart disease (CHD) increases with the number of risk factors. Thus, the clinical focus in prevention of CHD should be on patients with multiple risk factors. Both hypertension and a history of myocardial infarction are acknowledged risk factors for heart failure - the most severe form of CHD - but hypertension is more common. Analysis of data from the Framingham Heart Study shows that hypertension is associated with a greater population-attributable risk for heart failure. Angiotensin II, acting via the angiotensin II type 1 receptor, has been implicated in pathology associated with ischaemic heart disease and heart failure. Data on the efficacy of angiotensin-converting enzyme inhibitors in reducing cardiovascular events are comprehensive, with benefits demonstrated for patients with multiple risk factors, target organ damage, acute myocardial infarction and heart failure. Several recent trials have shown that angiotensin II receptor blockers reduce the progression of nephropathy in patients with type 2 diabetes mellitus. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) Trial Programme with provide a large body of data on the efficacy of the angiotensin II receptor blocker telmisartan in lowering cardiovascular morbidity and mortality in patients with multiple risk factors. (C) 2003 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.