The ONTARGET trial compared the angiotensin receptor blocker (ARB) telmisartan to the angiotensin converting enzyme (ACE) inhibitor ramipril and their combination in 25,620 patients with cardiovascular disease or diabetes. The trial found that telmisartan was noninferior to ramipril for the primary outcome of cardiovascular death, heart attack, stroke or hospitalization for heart failure. The combination of telmisartan and ramipril showed no additional benefit compared to ramipril alone and was associated with more side effects such as renal impairment.

1. ONTARGET (Ongoing Telmisartan Alone
and in Combination with Ramipril Global
Endpoint Trial)

2. ONTARGET (Ongoing Telmisartan Alone and in
Combination with Ramipril Global Endpoint Trial)
S Yusuf (McMaster University, Hamilton, ON)
American College of Cardiology 2008 Scientific Sessions
• Goal:
To test whether an ARB (which blocks the effects of angiotensin II without
enhancing bradykinin) was similarly effective to an ACE inhibitor and
whether the combination of an ACE inhibitor and an ARB may be superior
• Population and treatment:
25 620 patients ≥ 55 years of age with CHD or diabetes plus additional risk
factors without evidence of HF
Randomized to ramipril 10 mg/day, telmisartan 80 mg/day, or combination
of the two for a mean duration of 55 months
• Primary outcome:
A composite of CV death, MI, stroke, or hospitalization for HF
ARB=angiotensin=receptor blocker

3. ONTARGET: Results
• Telmisartan was shown to be noninferior to ramipril
Key results
Outcome Ramipril Telmisartan Combination Risk ratio (95% CI)a Risk ratio (95% CI)b
(n=8576), % (n=8542), % (n=8502), %
Primary end point 16.5 16.7 16.3 1.01 (0.94–1.09) 0.99 (0.92–1.07)
CV death/MI/stroke 14.1 13.9 14.1 0.99 (0.91–1.07) 1.00 (0.93–1.09)
MI 4.8 5.2 5.2 1.07 (0.94–1.22) 1.08 (0.94–1.23)
Stroke 4.7 4.3 4.4 0.91 (0.79–1.05) 0.93 (0.81–1.07)
CHF hospitalization 4.1 4.6 3.9 1.12 (0.97-1.29) 0.95 (0.82– 1.10)
CV death 7.0 7.0 7.3 1.00 (0.89–1.12) 1.04 (0.93–1.17)
Any death 11.8 11.6 12.5 0.98 (0.90–1.07) 1.07 (0.98–1.16)
Renal impairment 10.2 10.6 13.5 1.04 (0.96–1.14) 1.33 (1.22–1.44)
a. Telmisartan vs ramipril
b. Combination therapy vs ramipril

4. ONTARGET: Commentary*
"This was a great trial. It was large, with a simple design and a rigorous
noninferiority margin, so we can definitely say that telmisartan is similarly as
effective as ramipril. It asked two specific questions and got two clear answers."
- Dr Sanjay Kaul
"It lays all the ghosts to rest about suggestions of increased risk of MI with ARBs—
this trial shows that was all nonsense."
- Dr Peter Sleight
*All comments from ONTARGET: Clear messages from well-conducted study
(http://www.theheart.org/article/853429.do)

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