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1has shown that in patients at high cardiovascular (CV) risk a treatment regimen based on telmisartan or ramipril reduced to a similar degree clinic blood pressure (BP) and showed no significant difference in the incidence of CV morbid or fatal events. Clinic BP was reduced to a somewhat greater degree in patients treated with a combination of the 2 drugs (1.5-2.4 mm Hg systolic BP [SBP] and 0.8-1.4 mm Hg diastolic BP [DBP]), without, however, any significant difference in CV outcome. Because ramipril had been shown previously to reduce outcomes in high CV risk individuals 2 ; this led to the conclusion that telmisartan and ramipril have a similar protective effect, which is not enhanced by double blockade of the renin-angiotensin system, despite the potentially greater protection associated with a greater BP-lowering effect. Evidence is available that BP reductions induced by antihypertensive treatment cannot be precisely quantified if BP is measured in the clinic environment because clinic BP is affected to a variable degree by a transient increase known as the white coat effect. 4 Furthermore, clinic BP values are poorly reproducible, 5,6 and their treatment-induced changes reflect to only a modest degree the concomitant changes in daily life BP, 7-10 that is, a more reproducible 5 and prognostically important BP, which relates more steeply to CV morbidity and mortality. 11-17The ONTARGET included a prespecified substudy 18 focusing on ambulatory BP (ABP) to determine whether and to what extent treatment-induced changes in clinic BP correspond to daily life ABP. This article reports the results. Methods Patients and Monitoring ProceduresThe protocol of the ONTARGET has been described in detail previously.18 Briefly, men and women aged ≥55 years without symptomatic heart failure at entry and with a history of coronary Abstract-In the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial, telmisartan (T; 80 mg daily) and ramipril (R; 10 mg daily) caused similar clinic blood pressure (BP) reductions, with a similar incidence of cardiovascular and renal events. The R+T combination lowered clinic BP somewhat more with no further cardiovascular or renal protection. The aim of this substudy was to see whether these clinic BP changes reflected the changes of 24-hour BP, a BP with a better prognostic value. In 422 patients in whom 24-hour BP monitoring was performed either before or after 6 to 24 months of treatment, demographic and clinical characteristics were similar in the 3 treated groups. Twenty-four-hour systolic BP was similarly reduced by R (−2.0 mm Hg) and T (−2.1 mm Hg), whereas the reduction was more than twice as large in the T+R group (−5.3 mm Hg), which showed a lower on-treatment 24-hour BP also in additional patients (n=408) in whom ambulatory BP was performed only on-treatment. Twenty-four-hour systolic BP was ≈14 mm Hg lower than clinic systolic BP at baseline, whereas during treatment the 2 values became progressively closer as clinic systolic BP was more tightly controll...