Improving blood pressure control and clinical outcomes through initial use of combination therapy in stage 2 hypertension

Abstract

Poor control of clinic and 24-h blood pressure (BP) is associated with enhanced risk of all cardiovascular disease events. Certain patient groups including the elderly, African-Americans, and those with hypertension and comorbid disease are difficult to control, as are patients with stage 2 hypertension (systolic BP>or=160 mmHg or diastolic BP>or=100 mmHg). It has been estimated that more than two-thirds of high-risk hypertensive patients with stage 2 hypertension and all hypertensive patients with diabetes mellitus or kidney disease will require two or more antihypertensive agents from different therapeutic classes to reach BP goals. Combining agents with distinct and complementary modes of action can address different pathophysiologic mechanisms involved in hypertension and may lead to more complete and prompt reductions in BP. Tolerability may also improve, as certain classes of antihypertensive agents ameliorate adverse effects associated with other agents. Patients may benefit from fixed-dose combinations of drugs as this simplifies the regimen and may improve adherence with therapy, control of BP, and ultimately lead to reductions in cardiovascular events. Recent data and treatment guidelines support the use of a combination strategy as 'initial' antihypertensive therapy in high-risk patients with stage 2 hypertension.

The association of emotional well-being and marital status with treatment adherence among patients with hypertension

“…In particular, being White is associated with better hypertension control (Bosworth, Bartash, Olsen, & Steffens, 2003; Rehman, Hutchison, Hendrix, Okonofua, & Egan, 2005). It has been speculated that both biology and sociology play important roles in this relationship (White, 2008). Although gender shares a more complex relationship with BP, studies largely indicate that men are biologically predisposed to higher BP compared to women (Rosenthal & Oparil, 2000).…”

Is there a nonadherent subtype of hypertensive patient? A latent class analysis approach

“…Adherence to these guidelines is considered necessary to optimize hypertension control. Unfortunately, hypertension control remains suboptimal, leading to an increase in the incidence of sequelae of hypertension, including heart failure and end-stage renal disease 10–14…”

Effectiveness of initiating treatment with valsartan/hydrochlorothiazide in patients with stage-1 or stage-2 hypertension

“…4, 5, 13, 14, 15, 16 There is a consensus that initial combination therapy works for high-risk patients with stage-2 hypertension; however, this does not have current support as an optional treatment approach for wider use in primary hypertension. 11 Evidence supporting initial use of combination therapy for patients with stage-1 hypertension largely comes from recent findings from the ACCOMPLISH study. 17 Over 9000 patients with stage-1 or stage-2 hypertension were initiated with ACE-inhibitor+HCTZ or ACE-inhibitor+amlodipine combination therapy.…”

“…8, 9, 10, 11 The excellent tolerability and complementary BP-lowering effects of this combination makes it an ideal agent for initial use in patients with stage-1 and stage-2 hypertension. The primary arguments against initiating treatment with combination therapy for hypertension are based on clinical need and safety concerns.…”