Consider Combination Therapy for Patients with Low- and High-Risk Hypertension

Value-Based Care in Cardiometabolic Health May 2012, Vol 1, No 1
Wayne Kuznar

Chicago, IL—Combination therapy from the start should be considered for all patients in whom pharmacotherapy is chosen for the treatment of hypertension, said Kenneth A. Jamerson, MD, Professor of Medicine, University of Michigan Health System, Ann Arbor, at the 2012 American College of Cardiology meeting.

In high-risk patients, combining an angiotensin-converting enzyme (ACE) inhibitor with amlodipine is superior to diuretic-based combinations, he said, and in low-risk patients, combination therapy from the outset achieves faster blood pressure (BP) control.

Clinical trials in which monotherapies were compared were, in essence, trials of combination therapy, because patients required multiple drugs to reach prespecified targets, Dr Jamerson noted.

In making his case for target BP and the choice of therapy, he drew on his experience as part of the group that wrote the International Society on Hypertension in Blacks (ISHIB) Consensus Statement for the management of hypertension in blacks.

In patients without target-organ damage or overt cardiovascular disease (CVD), ISHIB consensus statement recommended modest lowering of the BP target to <135/85 mm Hg, he said, adding that an attempt to lower BP in these low-risk patients with up to 3 months of lifestyle modification is reasonable.

The lower BP goal is based on clinical trial evidence showing better outcomes with the lower goal versus a goal of <140 mm Hg systolic BP.

In low-risk patients, combination therapy offers more prompt and efficient control of BP compared with monotherapy.

For patients with target-organ damage or preclinical/clinical CVD, ISHIB recommended that BP be lowered and maintained consistently to <130/80 mm Hg.

“Combination therapy with an ACE inhibitor and amlodipine is superior to diuretic-based combination therapy in reducing cardiovascular disease morbidity and mortality in high-risk patients,” said Dr Jamerson.

The Anglo-Scandinavian Cardiac Out comes Trial (ASCOT) compared an amlodipine/perindopril combination with a combination of atenolol/ bendroflumethiazide in patients with hypertension and at least 3 other cardiovascular (CV) risk factors. All-cause mortality and CV mortality occurred significantly less often in the amlodipine/perindopril arm of the study.

Another trial to support the ACE inhibitor/ amlodipine combination was Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH), in which a combination of benazepril and amlodipine proved superior to benazepril and hydro chlorothiazide as initial therapy on the primary end point of time to first CV morbidity/mortality (20% relative risk reduction; P = .002) in patients with high-risk hypertension.

Diuretics should no longer be considered preferred therapy for hypertension; in fact, they should be relegated to add-on therapy, said Dr Jamerson. There is no BP-lowering advantage to diuretics, he said, and they require more laboratory monitoring than other classes of antihypertensives.

In addition, the cost advantage to diuretics has disappeared, because most other antihypertensive drug classes now have generic formulations.

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