Which Strategy Is More Effective for the Treatment of Cardiovascular Disease
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COMMENTARY
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Which Strategy Is More Effective for the Treatment of Cardiovascular Disease High-Dose Angiotensin II Type 1 Receptor Antagonist Monotherapy or Combination Therapy? Shin-ichiro Miura and Keijiro Saku Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
Abstract
Angiotensin II type 1 (AT1) receptor antagonists (blockers) [ARBs] are highly selective for the AT1 receptor and block the diverse effects of angiotensin II. When high BP is not controlled by low-dose ARB monotherapy, physicians need to employ another strategy, either high-dose ARB monotherapy or combination therapy with calcium channel antagonists (blockers) [CCBs], diuretics, or other agents. High-dose ARB monotherapy is more effective for decreasing proteinuria than low-dose ARB monotherapy or CCBs. Although the ARB valsartan has been shown to prevent coronary restenosis in a clinical study (Val-PREST [Valsartan for prevention of restenosis after stenting of type B2/C lesions]), it is still unclear whether ARBs help to prevent restenosis. The results reported by Peters in this issue highlight the relative efficacies of low- (80 mg/day) and high-dose valsartan (160–320 mg/day) for the prevention of in-stent restenosis after the implantation of bare-metal stents, and suggest that high-dose valsartan can reduce the in-stent restenosis rate, target lesion revascularization and target vessel revascularization rates, late lumen loss, and major adverse cardiac events rate more effectively than lowdose valsartan. A better understanding of the differences in the efficacies of high- and low-dose ARBs could be useful in the treatment of patients with cardiovascular disease and may resolve the issue of whether ARBs prevent coronary restenosis. Clinical benefits may be induced by complete blockade of the renin-angiotensin system using high-dose ARB monotherapy. Therefore, physicians need to select a strategy carefully; i.e. either high-dose ARB monotherapy or combination therapy.
The renin-angiotensin system (RAS) hormone angiotensin II plays a central role as a major regulator of BP, electrolyte balance and endocrine function related to vascular disease.[1] The angiotensin II type 1 (AT1) receptor for angiotensin II is a member of the G-protein coupled receptor superfamily. Treatment of hypertension can start with a single drug, which should initially be a low-dose AT1 receptor antagonist (blocker) [ARB], calcium channel antagonist (blocker) [CCB], or other agent. If high BP is not controlled by a low-dose ARB, either a high-dose ARB can be given or ARBs can be combined with an agent of a different class, e.g. CCB, diuretic, or other agent.[2] Stergiou et al.[3] reported a comparison of the additional antihypertensive effects of an ACE inhibitor, a CCB, and a diuretic in patients whose hypertension was not controlled by valsartan (ARB) monotherapy. Although significant additional antihyper-
tensive effects on average 24-hour ambulatory BP were obtained with ACE inhibitor
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