8. With every double digit
increase in BP, risk of
CV Mortality doubles
as well
9. 0
2
4
6
8
10
115/75 135/85 155/95 175/105
SBP/DBP (mmHg)
Lewington et al. Lancet. 2002;360:1903–1913.
Risk of CV Mortality Doubles With Each
20/10 mmHg BP Increase
Foldincreasein
relativeCVrisk
1-fold
2-fold
4-fold
8-fold
10. 2 mmHg
decrease in
mean SBP
10% reduction in
risk of stroke
mortality
7% reduction in
risk of IHD and
other vascular
disease mortality
Each 2 mmHg Decrease in SBP
Reduces CV Risk by 7–10%
Lewington et al. Lancet. 2002;360:1903–1913.
13. Several Guidelines Acknowledge That Most Patients
Need Combination Therapy to Achieve BP Goals
Combination treatment should
be considered as first choice
when there is CV high risk
14. Several Guidelines Acknowledge That Most Patients
Need Combination Therapy to Achieve BP Goals
Many patients will require more than
one drug to achieve adequate BP control
15. Even JNC-8 guidelines recommend use
of Combination Therapy where:
SBP is over 160mmHg or 20mmHg
above target BP
and/or
DBP is over 100mmHg or 10mmHg
above target BP
JNC
21. Renal Hyperfiltration Induced by
CCB is Reduced by ARB
Decreased
Glomerular pressure
and filtration
Amlodipine + Telmisartan
L-type Ca
channels
Increased
Glomerular pressure
and filtration
L-typeCa
channels
Peti-Peterdi; Abstract ESC 2010 (submitted).
Amlodipine
2
22. Calcium channel blockade results in compensatory activation
of the SNS, which, in turn, activates the renin angiotensin
system (RAS).
These effects tend to attenuate the BP-lowering efficacy of
CCBs. Administering an ARB counteracts these effects by
blocking the RAS, which in turn decreases SNS activity.
Because CCBs have diuretic and natriuretic properties, they
induce a state of negative sodium balance. This reinforces
the antihypertensive effects of ARBs.
3
Synergistic Anti-Hypertensive Effect of
‘ARB plus CCB’ Combination
23. 1.
CCB Induced
Peripheral Edema
is minimized by
ARB
2.
Renal Hyper
filtration Induced
by CCB is Reduced
by ARB
3.
Synergistic
Anti-Hypertensive
Effect of ‘ARB plus
CCB’ Combination
28. Irbesartan Candesartan Losartan Olmesartan Valsartan Telmisartan
Renal
Excretion
20% 40% 35% 40% 31% Less than 2%
Most favorable for
patients with Renal
Impairment
Telmisartan has least excretion through renal route
amongst all ARBs
Based on available online product information.
29. Telmisartan is the Most Studied Amongst ARBs in
Mortality and Morbidity Endpoint Trials
0
10,000
20,000
30,000
40,000
50,000
60,000
Numberofpatients
44,264
51,878
19,335
12,565
1,405
1. Schrader et al. Stroke. 2005;36:1218–1226; 2. http://www.roadmapstudy.org/resident.aspx; 3. Parving et al. N Engl J Med. 2001;345:870–878; 4. Lewis et al. N Engl J Med. 2001;345:851–860; 5.
Carson et al. J Card Fail. 2005;11:576–585; 6. Papademetriou et al. J Am Coll Cardiol. 2004;44:1175–1180; 7. www.atacand.com; 8. Brenner et al. N Engl J Med. 2001;345:861–869; 9. Pitt et al.
Lancet. 2000;355:1582–1587; 10. Dickstein et al. Lancet. 2002;360:752–760; 11. Dahlof et al. Lancet. 2002;359:955–1003; 12. Cohn et al. N Engl J Med. 2001;345:1667–1675; 13.
www.novartis.com; 14. Pfeffer et al. N Engl J Med. 2003;349:1893–1906; 15. Julius et al. Lancet. 2004;363:2022–2031; 15. www.ontarget-micardis.com.
6,405
4,449
Val-HeFT12
IRMA II3
LIFE11
ONTARGET®16
TRANSCEND®16
PRoFESS®16NAVIGATOR13
VALIANT14
VALUE15
OPTIMAAL10
ELITE II9
RENAAL8SCOPE6
CHARM7
MOSES1
IDNT4
I-Preserve5
ROADMAP2
Epro-
sartan
Lo-
sartan
Val-
sartan
Cande-
sartan
Irbe-
sartan
Telmi-
sartan
Olme-
sartan
32. This early morning surge is BP is
directly linked with high occurrence of
CV incidents such as Stroke & MI
during early morning hours
33. 12 2 4 6 8 10 12 2 4 6 8 10 12
PM AM
Surge in Blood Pressure
Surge in CV Events such as MI
and STROKE
With passing time, the Anti-Hypertensive effect of drug starts to wear off
ARBs other than Telmisartan
ARBs Other than Telmisartan
34. 12 2 4 6 8 10 12 2 4 6 8 10 12
PM AM PM
Surge in Blood Pressure
Surge in CV Events such as MI
and STROKE
24-Hour Plasma Half-life gives protection to Hypertensive Patients through-out the day, specially during early hours of the day
Over 30-Hour Plasma Half-life gives protection to Hypertensive Patients through-out the day, specially during early hours of the day
Superior BP Control and Protection
Telmisartan plus Amlodipine
Telmisartan
Amlodipine
Provides protection to your patients during early hours of the
day when cardiac events have high probability of occurrence
35. Telmisartan vs. Valsartan – last 6 hours
The MICADO-II Study
-12
-10
-8
-6
-4
-2
0
SBP DBP
Valsartan Telmisartan
BPcomparedwiththeinitialvalueinlast6hours
beforerepeatingdosing(mmhg)
* P = 0.02 versus Valsartan
**P = 0.01 versus Valsartan
*
**
White et al Am J Hypertension 2004;17:347-353
36. Telmisartan vs. Valsartan – last 6 hours
Mallion et al. (1999)
-12
-10
-8
-6
-4
-2
0
DBP
Losartan Telmisartan
DiastolicBPcomparedwithinitialvalue(mmHg)
P < 0.05 for Losartan
-12
-10
-8
-6
-4
-2
0
DBP
Ding et al. (2004)
Mallion et al. J Hum Hypertens 1999;13: 657-664
Ding et al. Int J Clin Pract Suppl 2004;58 16-22
37. Telmisartan/Amlodipine vs. Valsartan / Amlodipine
-12
-10
-8
-6
-4
-2
0
4 Weeks 8 Weeks 12 Weeks
MeandropinBPfromBaseline(mmHg)
*SBP
DBP
Replacement of Valsartan by Telmisartan reduced mean SBP and DBP by 7.1 and 6.5
mmHg at 4 weeks, 6.9 and 5 mmHg at 8 weeks, 10.5 and 7 mmHg at 12 weeks
respectively. All patients were taking 5mg amlodipine
Oxi Med Cell Longev. (2010) 3(5): 342-346
38. Telmisartan Plus Amlodipine Has a Safety and
Tolerability Profile Similar to Placebo
0 0
4.3 4.3
0 0 0
2.2
10.9
0
1.3
0.9 0.9
0.6
1.9
1.3
2.2
1.3
6.0
7.8
1.1 1.1 1.1 1.1
1.4
1.8
2.2
3.0
4.7 4.8
0
2
4
6
8
10
12
Patientswith
AEs>1%incidence(%)
A mono (n = 319) T/A (n = 789)Placebo (n = 46)
Littlejohn et al. J Clin Hypertens. 2009;11:207–213.
Fatigue Oedema Sinusitis Naso-
pharyn-
gitis
Upper
respiratory
tract
infection
Influenza Back
pain
Dizzi-
ness
Headache Peripheral
oedema
39. An Effective Anti-Hypertensive Combination
Providing Holistic and Sustained BP Control
+
Compared to other CCBs,
Amlodipine has:
- Longest Plasma Half life
Compared to other ARBs, Telmisartan has:
- Longest Plasma Half life
- Highest level of Distribution
- Lowest Renal Excretion
- Superior BP Control & Protection
