The myth of Janus: The two faces of renal outcomes in the ONTARGET study

Angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) and ACE inhibitors are known to reduce proteinuria and, thus, progression towards renal and cardiovascular outcomes. Recent data from the ONTARGET study (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) have demonstrated a substantial equivalence between ACE inhibitors and ARBs in preventing major cardiovascular events in patients aged 55 years or older with established atherosclerotic vascular disease or with diabetes mellitus with end-organ damage, while their combination did not seem to confer additional cardiovascular benefits, in the presence of increased incidence of adverse effects and discontinuation. More recently, the results of a pre-specified analysis on the renal effects of ramipril, telmisartan and their combination have become available, confirming the equivalence between ACE inhibitors and ARBs in terms of renal outcomes. Although combination therapy reduces proteinuria to a greater extent than monotherapy, overall it worsens major renal outcomes.