ARBs and ACEIs are safe and effective in Hypertension, after MI and in Heart Failure

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 ARBs and ACEIs are safe and effective in
Hypertension, after MI and in Heart Failure

They have similar safety and efficacy but ARBs
are better tolerated-Asad Pathan

Proteinuria level predicts stroke and CHD events
in Type 2 diabetes-Bilal Jamil

KARACHI:  ARBs and ACEIs are safe and effective in hypertension, after myocardial infarction as well as in Heart Failure.  Both have similar safety and efficacy though ARBs are better tolerated. This was stated by Dr. Asad Pathan Director Interventional Cardiology at Tabba Heart Institute, Karachi. He was speaking on ARBs in Cardiology at a seminar organized by PharmEvo Pakistan here on May 28th 20916. The seminar was chaired by Prof. Tahir Hussain, Head of the Dept. of Medicine at Karachi Medical and Dental College while Dr. Fatema Jawad Consultant Endocrinologist was other member of the Experts Panel. The other speaker in the seminar was Dr. Bilal Jamil, Consultant Nephrologist and Medical Director Tabba Kidney Center, Karachi.

Continuing Dr. Asad Pathan said that cough is a known side effect of ACIs which is about 9% and it may be a bit higher in our patients but it is not a serious side effect though the patent may not like to take this medication. He discussed in detail Angiotensin-II as a cardiac and renal toxin, RAS effects, Angiotensin –II effects in target organ damage, stroke and heart failure. He then discussed mechanism of action of RASS modulators including ARBs and ACEIs, their role in hypertension, Congestive Heart failure, Renal Impairment and post myocardial infarction. He gave highlights from various ARB trials like AIRE, SAVE, TRACE etc., which all showed that they reduce hypertension and cardiovascular events. Studies with Losartan showed that it reduces mortality, stroke and MI. In OPTIMAL trial Losartan was compared with Captopril and it showed that there was no significant difference. In CHARM study which included 7601 patients, Candesartan was compared with placebo and it also showed that there was reduction in hypertension, heart failure and mortality. VALIANT trial compared Valsartan with Captopril which showed that both the drugs were as effective in reducing mortality, Myocardial infarction and heart failure.

Val Heft study   also showed that there was no significant difference in safety and efficacy of various ARBs. ONTARGET study enrolled 25,620 patients in which one groupof patients was given Ramipril, other Telmisartan and the third got combination of both these drugs. Again there was similar outcome. Speaking about the role of ACEIs and ARBs in reduction of diabetes mellitus, Dr. Asad Pathan said that ARBs trial in Heart Failure using a dose of 50mg and 150mg showed that there was reductionin  heart failure as well as hospitalization. In all there have been one hundred trials including seventy four Randomized Clinical Trials with ARBS and ACEIs and all have shown that they have similar long term blood pressure lowering effects, he added.

Dr. Bilal Jamil discussed the role of ARB s in chronic kidney disease. He pointed out that dialysis once started is for life long, hence we must find out how to prevent patient going on dialysis.  He discussed in detail when, why and how to intervene in these patients and what is the right time for intervention. His presentation was based on Guidelines by the Kidney International on CKD Evaluation and Management.(www.kdigo.org). Speaking about the criteria for CKD he mentioned decreasedGFR(<3MO) He then referred to staging in chronic kidney disease, evaluation of albuminuria, excluding other conditions like UTI which also case albuminuria.

Continuing Dr. Bilal Jamil said that serum creatinine and cGFR should be used for assessment.  IDMS should be used for estimation of creatinine.  Speaking about  predicting prognosis he said that if the patient has persistent micro albuminuria and develops protein micro albuminuria start treatment. Micro albuminuria predicts future coronary events in patients with Type 2 diabetes. Proteinuria level also predicts stroke and CHD events in Type 2 diabetes. Micro albuminuriapredicts coronary events in patients with essential hypertension. ARBs are safe in chronic kidney disease. They reduce micro albuminuria in type 2 diabetes, slows progression of disease and the disease is also prevented. Hence we need to address this issue of micro albuminuria.  ACEIs and ARBs also slow down the progression of chronic kidney disease though ARBs have a better advantage, he concluded.

Dr. Fatema Jawad in her remarks said that diabetes and hypertension are both increasing in low income countries hence we have to treat these patients in time and prevent complications. Patients with cardiovascular disease and diabetes have four times more chances of developing kidney problems. Hence it is important that we should keep the blood glucose and blood pressure under control.Diabetes leads to renal failure and the patient has to be put on dialysis. The speakers have highlighted when we should intervene and help our patients so that they remain away from developing these complications. With BP control and Blood Glucose control, micro albuminuria can be reduced and also reverted.

Prof. Tahir Hussain said that  the data presented by both the speakers has shown that there is hardly any difference in safety and efficacy of  ACEIs and ARBs, only ARBs are a  little better tolerated. These drugs reduce morbidity and mortality in hypertension, cardiovascular disease. There are certain pitfalls in chronic kidney disease as the patients come too late. Hope is still there and these drugs have a potential as their role in CKD is very well established. Replying to a question regarding formation of solid tumors with ARBs, Dr. Asad Pathan said that for this one needs more data but the ARBs have been on the market not for too long. Responding to a question from the audience Dr. Bilal Jamil said that in CKD one can combine both ARBs and ACEIs but it is advisable to start with one drug and then if there is no response, add on another drug. Patients with LVF and Hypertension, it was pointed out, need to be monitored carefully. Similarly in case of Hypokalemia Dr. Asad Pathan said, one need not stop all the drugs, reduce it and then see the effects. Later Mr. Shakil Ahmad Director Marketing and Sales PharmEvo thanked the guest speakers, chairperson and the expert’s panel for highlighting the safety and efficacy of ARBs in cardiology and renal disorders.