When it comes to treating high blood pressure, not all anti-hypertensive medications are equal, and results of the ATTEMPT-CVD trial suggest that telmisartan, an angiotensin II receptor blocker (ARB) might have benefits over non-ARB treatment.

The Hot Line results, presented at ESC Congress 2015, and published simultaneously in the European Journal of Preventive Cardiology, are the first evidence that ARBs may have a better impact on two biomarkers of cardiovascular disease (CVD) compared to non-ARBs, said lead investigator Hisao Ogawa, MD, from Kumamoto University, in Kumamoto City, Japan.

However, the trial did not show a significant difference between the treatments in either cardiovascular or renal events.

ATTEMPT-CVD measured the impact of both telmisartan and non-ARBs on urinary albumin creatinine ratio (UACR) and plasma brain natriuretic peptide (BNP).

Patients with hypertension from 168 institutions in Japan were randomized to receive telmisartan (n=615) or a non-ARB antihypertensive drug (n=613) and followed for three years.

The primary efficacy endpoints were changes from baseline in UACR and plasma BNP levels. Elevations in either of these biomarkers are considered risk factors for CVD.  Secondary endpoints were changes in other biomarkers, including serum high-sensitivity C-reactive protein (hsCRP) levels, urinary 8-hydroxy-deoxy-guanosine (8-OHdG), serum adiponectin, estimated glomerular filtration rate (eGFR), and high-molecular weight adiponectin levels.

Another secondary endpoint was time until occurrence of a composite of cardiovascular events consisting of cerebral events, coronary events, cardiac events, aortic/peripheral arterial events, complication of diabetes, and aggravation of renal function.

The study found that, despite similar blood pressure control in both arms, patients treated with the ARB had a smaller increase in plasma BNP and a greater decrease in UACR than non-ARB treated patients.

By 36 months, UACR had decreased by12.2 mg/gCr in the ARB group compared to a decrease of 4.1 mg/gCr in the non-ARB group (P < 0.001).

Similarly, plasma BNP had increased by 0.5 pg/ml in the ARB group and by 3.8 pg/ml in the non-ARB group (P = 0.044).

Fewer cardiovascular events occurred in the ARB group, but the difference was not statistically significant (hazard ratio 0.71, P = 0.14).

Other biomarkers were not different between the two groups except for serum adiponectin, which showed a larger increase (P = 0.041), indicating better CVD health, and eGFR which showed a larger decrease (P < 0.001) indicating poorer renal function in the ARB group compared to the non-ARB group.

"It is well known that a slight but significant decrease in eGFR is not associated with poor outcome and may not be clinically relevant," noted Dr. Ogawa. In fact, the study showed that baseline levels of UACR and plasma BNP levels were associated with cardiovascular risk, but adiponectin and eGFR levels were not.

"Further study is needed to determine the significance of follow-up of BNP and UACR for cardiovascular and renal risk in hypertensive patients," he concluded.    
This study was supported by the Japan Foundation for Aging and Health, which has received unrestricted funding from individuals and companies including Boehringer Ingelheim.

Dr. Ogawa has received grants from Astellas Pharma Inc., Bayer Yakuhin Ltd., Bristol Myers Squibb, Chugai Pharmaceutical Co. Ltd., Daiichi Sankyo Co. Ltd., Dainippon Sumitimo Pharma Co. Ltd., Mochida Pharmaceutical Co. Ltd., MSD. K.K., Novartis Pharma K.K., Ono Pharmaceutical Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Pfizer Japan Inc., Sanofi K.K., Shionogi & Co., Ltd., Takeda Pharmaceutical Co., Ltd., and personal fees from Actelion Pharmaceuticals Japan Ltd., Astra Zeneca K.K., Bayer Yakuhin Ltd., Boehringer Ingelheim Japan, Daiichi Sankyo LCo. Ltd., Eisai Co. Ltd., Kowa Co. Ltd., Kyowa Hakko Kirin Co. Ltd., Mitsubishi Tanabe Pharma, MSD K.K., Otsuka Pharmaceutical Co. Ltd., Pfizer Japan Inc., Sanofi K.K., Takeda Pharmaceutical Co. Ltd., and Teijin Pharma Co. Ltd.