The Presenter: Björn Dahlöf, MD, Göteborg University, Sweden The Study: A randomized, double-blind, parallel group study of losartan (a selective angiotensin I receptor blocker)-based versus atenolol-based therapy in 9193 patients with essential hypertension and ECG evidence of left ventricular hypertrophy (LVH). 1 To base therapy (both up to a maximum of 100 mg), diuretics and other antihypertensive agents (excluding angiotensin-converting enzyme inhibitors, other angiotensin receptor

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... or ␤-blockers) could be added. Study therapy was continued for Յ4 years; the primary end point was the composite of cardiovascular mortality, stroke, and myocardial infarction. The Results: The degree of blood pressure control was similar between groups. There were significantly fewer cardiovascular events in the losartan group (11% versus 13%, Pϭ0.021), and the primary difference was a reduction in the number of strokes (5% versus 7%, Pϭ0.001). Regression of LVH on the ECG was also significantly more frequent with losartan. Intriguingly, with losartan, there was a 25% reduction in the number of patients who developed diabetes, and in the subgroup of patients with diabetes, total mortality was reduced by 39%. Summary: In hypertensive patients with ECG evidence of LVH, outcomes with losartan are significantly better than with atenolol. This benefit is particularly manifested in patients with diabetes. It is also worth noting that the likelihood of developing diabetes was also reduced with losartan. The Study: A double-blind, randomized parallel group trial comparing eplerenone (a selective aldosterone blocker, 200 mg/d), enalapril (an angiotensin-converting enzyme inhibitor, 40 mg/d), and eplerenone (200 mg/d) plus enalapril (10 mg/d) in 202 patients with essential hypertension and left ventricular hypertrophy on ECG. Additional add-on antihypertensive therapy with hydrochlorothiazide and/or amlodipine was permitted. Study drug therapy was continued for 9 months. The primary end point was left ventricular mass, as measured by MRI. The study was designed as a noninferiority study to show that left ventricular mass would not differ between groups by Ͼ15 g. The Results: The mean change in left ventricular mass was Ϫ14.5 g in the eplerenone group, Ϫ19.7 g in the enalapril group, and Ϫ27.2 g in the eplerenone/enalapril group. Blood pressure was reduced in all 3 groups, with a trend toward greater reduction with combination therapy. Microalbuminuria and the change in urinary albumin/creatinine ratio were significantly improved with combination therapy. Summary: The selective aldosterone antagonist eplerenone alone appears to be as good as enalapril alone, and their combination may be better than either alone in reducing some end-organ sequelae of hypertension.