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Two controversies in hypertension were the subject of a pro vs contra debate on Aug 28th.
Use of ARB as first line therapy was defended by Professor Xavier Girerd from Paris, who pointed out the outstanding efficacy and lack of side effects in this group of drugs. Most ARBs are long acting, permitting once a day dosing and they are often used as highly effective monotherapy. There are few side effects and they are among the drugs least probable to be discontinued by the patient. There are proven effects on blood pressure and cardiac endpoints and a reduction of proteinuria. All these factors favor their use as first- line drugs in hypertension.
His opponent Professor Frank Ruschitzka from Zurich acknowledged the efficacy of ARB with respect to blood pressure reduction, but pointed out that results from several trials indicated that a consistent finding in several studies is a lack of reduction in the rate of acute myocardial infarction which would be expected for the degree of BP lowering. ARBs are effective in HT, but fail to reduce MI and stroke. On the other hand several trials of ACEI in hypertensives without HF consistently show reduced rates of MI, stroke and cardiac death. He speculated that AT1 blockade induces a unopposed high level of AT2, AT2 and AR4 which might be related to plaque instability.
Stenting for arterosclerotic renal artery stenosis (RAS) was defended by Professor Jaap Beutler from Netherlands who pointed out that metanalyses have shown an effect on blood pressure, but that this was not clearly confirmed in two recent randomized trials; the STAR and ASTRAL studies which compare medical therapy and stenting in RAS. However, the trials were hampered by the inclusion of patients with less severe stenosis, incidental asymptomatic RAS and renal failure patients and the exclusion of patients definitively needing revascularization.
His rebuttal was made by Professor Pierre-Francois Plouin from Paris who pointed out that although stenting of RAS improved vessel patency, there was, according to the recent trials, no improvement with respect to blood pressure control or renal function. RAS is not a disease confined to the kidney vessel as these patients have a high systolic BP reflecting extensive disease with stiff arteries and they often have reduced GFR, indicating bilateral parenchymal tissue injury. RAS patients have a high incidence of CAD, PAD, CHF, stroke etc and should always receive optimal medical therapy with statins, ACEI/ARB etc. Responders to RAS stenting are difficult to indentify.
Both speakers seemed to agree though that RAS should be sought out and treated in some patients with resistant hypertension, especially patients with flash pulmonary oedema, a reduction in kidney function and size and patients with severe HT intolerant to ACEI/ARB
Controversies in hypertension