Hypertension remains the leading cause of mortality and the third largest cause of disability worldwide despite decades of concentrated effort combatting the disease [1]. Blood pressure (BP) reduction is the key issue in reducing hypertension-induced morbidity and mortality, although results of some antihypertensive drugs beyond the BP-lowering effect also have significant importance [2]. Despite this, the proportion of patients with acceptable BP control is too low in many countries, even among those who are diagnosed and treated [3].
This is true in Europe as well, with the proportion of patients in the region of 30%—including those diagnosed and treated [3]. Reasons for the lack of BP control are multiple, including low patient adherence, physician inertia, and inefficient health care structure. Beside these, the functional and structural mechanisms contributing to high BP values also limit the BP-lowering effect of the drug [4]. Thus, a multiple approach should be implemented in order to achieve maximal success. Finding the most suitable antihypertensive treatment is most important. Consequently, when prescribing antihypertensive treatment, selection of the class of drugs and pharmacokinetic and pharmacodynamic properties of a specific compound must be considered. Likewise, the necessity to combine drugs in order to achieve the maximal efficacy with the lowest rate of side effects has been strongly recommended in the Reappraisal of the Guidelines published by the European Society of Hypertension (ESH) [5]. Combining two agents with complementary mechanisms of action can provide BP control that is not only effective, but rapid as well.
Two classes of agents that are well suited to combination therapy are the angiotensin-converting enzyme (ACE) inhibitors and the angiotensin receptor blockers (ARBs), due to their favorable tolerability profile. This profile allows these agents to be used in combination with other agents without increasing the incidence of adverse events [6]. Although ACE inhibitors and ARBs are well tolerated, certain undesirable effects, notably cough and angioedema, are associated with the use of ACE inhibitors. The efficacy and tolerability of ARBs, as well as other ancillary benefits, has led to their rapid uptake and widespread use. Results from clinical studies have demonstrated the efficacy of ARBs as antihypertensive agents, and large-scale clinical investigations have shown that their efficacy is paralleled by reductions in the risk of cardiovascular and renal events such as stroke, ischemic heart disease, diabetic nephropathy, and prevention of microalbuminuria in patients with diabetes [7-13]. Among ARBs, olmesartan is one of the most potent drugs with long-lasting 24-h antihypertensive activity [14,15].
In this issue of Hot Topics in Hypertension, Michel Burnier and Grégoire Wuerzner review the potential of olmesartan-based therapies, which reduce the undesired actions of angiotensin II. These therapies, in addition to their availability in monotherapy, have a wide spectrum of fixed-dose combinations as recommended by the ESH. Olmesartan can be combined with hydrochlorothiazide or amlodipine or even as a triple combination of these three. The authors present a comprehensive and thought-provoking summary of olmesartan and its potential combinations.

REFERENCES

1. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-1360.

2. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007;25:1105-1187.

3. Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens 2004;22:11-19.

4. Redon J, Brunner HR, Ferri C, Hilgers KF, Kolloch R, van Montfrans G. Practical solutions to the challenges of uncontrolled hypertension: a white paper. J Hypertens 2008;26(Suppl):S1-S14.

5. Mancia G, Laurent S, Agabiti-Rosei E, et al; European Society of Hypertension. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009;27:2121-2158.

6. Law MR, Wald NJ, Morris JK, et al. Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ 2003;326(7404):1427.

7. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345(12):861–869.

8. Parving HH, Lehnert H, Brochner-Mortensen J, et al. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001;345(12):870-878.

9. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359(9311):995-1003.

10. Lithell H, Hansson L, Skoog I, et al. The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial. J Hypertens 2003;21(5):875-886.

11. McMurray JJ, Ostergren J, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet 2003;362(9386):767-771.

12. Turnbull F. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 2003;362(9395):1527-1535.

13. Haller H, Ito S, Izzo JL Jr, et al; ROADMAP Trial Investigators. Olmesartan for the delay or prevention of microalbuminuria in type 2 diabetes. N Engl J Med 2011;364:907-917.

14. Fabia MJ, Abdilla N, Oltra R, Fernandez C, Redon J. Antihypertensive activity of angiotensin II AT1 receptor antagonists: a systematic review of studies with 24 h ambulatory blood pressure monitoring. J Hypertens 2007;25:1327-1336.

15. Redon J, Fabia MJ. Efficacy in angiotensin receptor blockade: a comparative review of data with olmesartan. J Renin Angiotensin Aldosterone Syst 2009;10:147-156.