Treatment of microalbuminuria in hypertensive subjects with elevated cardiovascular risk: Results of the IMPROVE trial

Abstract

Microalbuminuria independently predicts increased cardiovascular risk in hypertensive patients, especially in those with concomitant diabetes or established cardiovascular disease. Drugs that target the renin-angiotensin-aldosterone system reduce microalbuminuria regardless of diabetic status. The Irbesartan in the Management of PROteinuric patients at high risk for Vascular Events was a multicenter, randomized, double-blind, placebo-controlled paralleled group study in which hypertensive patients with microalbuminuria and increased cardiovascular risk were randomized to 20 weeks treatment with ramipril plus irbesartan or to ramipril plus placebo. Patients discontinued or tapered previous antihypertensive therapy during a 14-day placebo lead-in period. Change in albumin excretion rate from baseline to week 20 was the primary end point. Adjusted week 20 baseline geometric ratios for ramipril plus irbesartan and ramipril plus placebo were not significantly different. Although differences in blood pressure reductions were observed between the two treatments, these changes did not affect microalbuminuria. More patients on dual therapy achieved target blood pressure goals at week 20 than with monotherapy. The incidence of adverse effects and treatment-related adverse effects was similar in both groups. Our results suggest that patients with cardiovascular risk and relatively low albumin excretion rates in early-stage disease may only require monotherapy with renin-angiotensin-aldosterone blocking agents.

Inhibition of the Renin-Angiotensin System in Chronic Kidney Disease: A Critical Look to Single and Dual Blockade

“…Four hundred and five patients at high cardiovascular risk, most with diabetic kidney disease, were randomised to receive either ramipril plus irbesartan or ramipril alone [27]. Despite a better blood pressure control in patients receiving the combination regimen, after 20 weeks of follow-up, the changes in the geometric mean of albumin excretion rate from baseline were similar in the 2 groups.…”

“…Recently, the Irbesartan in the Management of Proteinuric Patients at High Risk for Vascular Events (IMPROVE) [27 ]study, which is a large randomised controlled trial, questioned the antiproteinuric effect of this therapeutic strategy. Four hundred and five patients at high cardiovascular risk, most with diabetic kidney disease, were randomised to receive either ramipril plus irbesartan or ramipril alone [27].…”

Bloqueo dual del sistema renina-angiotensina frente a la monoterapia: revisión sistemática y metaanálisis acumulativo de ensayos clínicos y estudios observacionales

“…Sin embargo, este hallazgo sería contrario a los resultados obtenidos en grandes estudios que valoran acontecimientos renales 3,4,21,30 . Algunas guías de práctica clínica (como es el caso de las guías europeas 2013 sobre el manejo de la hipertensión arterial y diabetes 31,32 ) desaconsejan el uso de la combinación de dos inhibidores del RAS. La ficha técnica de algunos medicamentos no recomienda el uso concomitante de IECA y ARA-II y en los casos individualmente definidos se recomienda seguir estrechamente la función renal y las concentraciones sanguíneas de potasio 33,34 .…”

Drug and Diabetic Nephropathy

“…Subgroup analyses showed the largest reduction in albuminuria occurred in patients with overt nephropathy but it did not reach statistical significance 118 .…”