ACE Inhibitor : The Cornerstone of

Hypertension Treatment
14 millions of new hypertensive patients per
year

Worldwide
600 million hypertensive
patients in 1980

1 billion hypertensive patients

in 2008

14 million newly diagnosed hypertensive patients

per year
WHO/DCO/WHD/2013.2
 Hypertension causes end-
end-organ damage

Chobanian AV, et al. JAMA. 2003;289:2560-2572

WHICH ANTIHYPERTENSIVES WE
SHOULD CHOOSE?
Hypertension Guidelines: an ultimate goal

Goals of treatment
“The primary goal of treatment of the hypertensive patient is to achieve
the maximum reduction in the long-term total risk of cardiovascular
morbidity and mortality.”

Therapeutic Management of Hypertension

“Antihypertensive treatment translates into significant reductions of
cardiovascular morbidity while having a less significant effect on
all cause mortality.”
JNC 8: Treatment Algorithm of Hypertension
Evidence versus conventional opinion
is the vision of a mean effect adapted
to the antihypertensive treatment?

Antihypertensive drugs are so different.

Even in the same drug class, there are huge differences
in terms of duration of action and dosage.
 Atherosclerosis-
Atherosclerosis-promoting actions
of Ang II and protective effects of bradykinin
ACE
Inactive Vasodilatation
peptides Bradykinin Prostacycline Protection
NO against AII
tPA

ACE-I

Vasoconstriction
VCAM, ICAM Endothelial-
Growth Factor dysfunction
Oxydative stess Inflammation
Ang I Ang II PAI-1 Coagulation
VSMC Atherogenesi
ACE proliferation s
Matrix degradation

Ferrari R. Expert Rev Cardiovasc Ther 2005;3:15-29

 Difference between ACE inhibitors and ARBs
on mortality reductions in recent meta-
meta-analyses

1. van Vark LC, et al. Eur Heart J. 2012;33(16):2088-2097. 2. Lv J, et al. Cochrane Database Syst Rev. 2012;12:CD004136. 3. Baker WL, et al. Ann
9 Intern Med. 2009;151(12):861-871. 4. Savarese G, et al. J Am Coll Cardiol.15;61(2):131-142. 5. Hara et al. Am J Cardiol. 2014;114(1):1-8
 Different Effect even from same class inhibition

Perindoprilat Perindopril

1. Ferrari R. Angiotensin-converting enzyme inhibition in cardiovascular disease: evidence with perindopril. Expert Rev Cardiovasc Ther. 2005;3:15-29. 2. Ceconi C, Francolini G,
Olivares A, et al. Angiotensin-converting enzyme (ACE) inhibitors have different selectivity for bradykinin binding sites of human somatic ACE. Eur J Pharmacol. 2007;577:1-6.
Perindopril improved Endothelial Function of
Hypertensive Patients
 Perindopril: Real BP Control (24-
(24-h BP Control)

PERINDOPRIL 81-100%

37-40%

64-66%

35%

22%

47%

58-78%

69-76%

>60%

80%

≥97%

DIASTOLIC BLOOD PRESSURE TROUGH-TO-PEAK RATIOS

1. Physicians’ Desk Reference. 55th ed. Montvale, NJ: Medical Economics Company; 2001. 2. Morgan T. Br J Cardiol. 1995;(suppl 1):57-
59.
 Perindopril is more effective than
other RAAS blocker

Nedogoda
Study1
Bioprexum Losartan Telmisartan Enalapril
0

-10

-12 -11
mmHg
mmHg
-15
-20 mmHg

-22
mmHg
-30
Mean 24-hour ∆ 8BP
(mmHg)
*p<0.05 vs Coversyl 10 mg
 Perindopril reduce cardiac and renal
events in diabetic patients

Per+Ind, perindopril+indapamide fixed combination

†Non-fatal MI or death from coronary heart disease

‡Unstable angina requiring hospitalisation, coronary revascularisation or silent MI

Perindopril based Therapy give consistent
mortality benefit after 10 year follow up
Perindopril provides better mortality benefit

Perindopril
Can we go further to protect our hypertension patients ?
Conclusion

Not all antihypertensive (RAAS-I) is the same.

The right choice of antihypertensive will help

doctor to prevent target organ damage caused
by hypertension.

Perindopril is the most proven ACE-I that is

effective in monotherapy and should be chosen
as based in combination therapy.
Thank You
 ACE-induced cough is largely overestimated
Randomized double-blind trial in the Philippines
302 patients

Cilazapril Enalapril Perindopril Imidapril

70 patients 82 patients 73 patients 76 patients
• Perindopril has the lowest
incidence of cough
Cough incidence after 6 weeks
26 patients 26 patients 17 patients 19 patients • Real cough is overestimated
(-65% compared to first
-65% incidence with perindopril)
Real cough incidence (stop/re-start treatment)
16 patients 18 patients 6 patients 10 patients
23% 22% 13%
8%
Tumanan-Mendoza BA et al. J Clin Epidemiol. 2007;60;547-553.

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