Letters
Volume 199 - Issue 4

National guidelines for the management of absolute cardiovascular disease risk

Author:  Timothy Usherwood

Med J Aust 2013; 199 (4): 243-244. || doi: 10.5694/mja13.10248
Published online: 2 September 2013
To the Editor: Guidelines for the management of absolute cardiovascular disease risk, published recently by the National Vascular Disease Prevention Alliance, contain the following evidence-based recommendations (EBRs) for choice of blood pressure-lowering therapy: EBR 11: Treatment should begin with any one of the following agents: · ACE [angiotensin-converting enzyme] inhibitor · Angiotensin receptor blocker · Calcium channel blocker · Low dose thiazide or thiazide-like diuretic. EBR 12: If monotherapy does not ...
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To the Editor: Guidelines for the management of absolute cardiovascular disease risk, published recently by the National Vascular Disease Prevention Alliance, contain the following evidence-based recommendations (EBRs) for choice of blood pressure-lowering therapy:

EBR 11: Treatment should begin with any one of the following agents:

• ACE [angiotensin-converting enzyme] inhibitor

• Angiotensin receptor blocker

• Calcium channel blocker

• Low dose thiazide or thiazide-like diuretic.

EBR 12: If monotherapy does not sufficiently reduce blood pressure add a second agent from a different pharmacological class.1

Taken together, these two recommendations imply that, if monotherapy with an ACE inhibitor is ineffective, then an angiotensin receptor blocker could be added, or vice versa. Although a number of studies have shown that such a combination is effective in reducing blood pressure beyond the effect of a single drug, and there may be specific exceptions when this combination is appropriate, such use has not been shown to improve hard clinical outcomes and, in many cases, is likely to be dangerous.

The largest published comparison of therapy with an ACE inhibitor, angiotensin receptor blocker or both is the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET).2 Patients with established vascular disease or diabetes plus end-organ damage were randomly allocated to therapy with telmisartan, ramipril or both. Participants receiving the combination treatment had a higher risk of adverse effects than those receiving a single agent, without clinical benefit.

This year, a meta-analysis of randomised trials comparing dual blockade of the renin–angiotensin system with monotherapy concluded:

Although dual blockade of the renin–angiotensin system may have seemingly beneficial effects on certain surrogate endpoints, it failed to reduce mortality and was associated with an excessive risk of adverse events such as hyperkalaemia, hypotension, and renal failure compared with monotherapy.3

International guidelines recommend against combining an ACE inhibitor and angiotensin receptor blocker to treat uncomplicated hypertension.4,5 The Australian guidelines for chronic kidney disease management in general practice,6 and the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people7 also recommend against this combination.

The National Vascular Disease Prevention Alliance guidelines identify two other drug combinations that can be unsafe (Practice Point 17).1 Combining an ACE inhibitor with an angiotensin receptor blocker should be added to this list.

Author

  • Timothy Usherwood1
  • 1. Department of General Practice, University of Sydney, Sydney, NSW.

Correspondence: timu@med.usyd.edu.au

Competing interests

I was an author of the Australian guidelines for chronic kidney disease management in general practice,6 and the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.7

References

View this article on Wiley Online Library