Managing hypertension: a question of STRATHE

Abstract

Current international guidelines recommend the use of therapeutic strategies with proven efficacy in the management of hypertension to achieve a target blood pressure of o140/90 mmHg. After lifestyle intervention, they endorse three different management strategies: (i) first-line use of a low-dose combination of two agents from different antihypertensive classes, with the option of doubling the dose of the combination; (ii) use of a sequential monotherapy strategy, initiating with one antihypertensive to be replaced by another one from a different class, if necessary; and (iii) a stepped care strategy, initiating with one antihypertensive, and increasing the dose or adding another agent from a different class, if necessary. The objective of the STRAtegies of Treatment in Hypertension: Evaluation (STRATHE) study was to compare the efficacy and tolerability of these three treatment strategies in patients with uncomplicated essential hypertension (n ¼ 533). In all, 62% of the patients in the low-dose combination group were normalised (o140/90 mmHg), compared with 49% of the sequential monotherapy group (P ¼ 0.01) and 47% of the stepped-care group (P ¼ 0.005). The percentage of patients achieving normalisation without experiencing drug-related adverse events was also significantly higher in the low-dose combination group (56%) than in the sequential monotherapy (42%, P ¼ 0.001) and stepped-care groups (42%, P ¼ 0.004), consistent with the observation that the reduced dosage of the antihypertensive agents in such preparations translates into improved acceptability. The results of STRATHE provide further support for an antihypertensive management strategy involving the low-dose combination of perindopril (2 mg) and indapamide (0.625 mg).

Initial Combination Therapy Reduces the Risk of Cardiovascular Events in Hypertensive Patients

“…These findings are consistent with previous studies that document a lag time in BP goal attainment in patients who are initiated on monotherapy and later up-titrated to combination treatment. 9,12,[14][15][16] The length of this lag time is variable and is highly dependent on the time course of drug titration. In this study, in which treatment decisions were made by individual physicians rather than a research protocol, up-titration occurred at an average of 13.5 months after treatment initiation.…”

“…7,8 Clinical trials and observational studies indicate that initiating treatment with a 2-drug combination results in more rapid achievement of target BP compared with initial monotherapy. [9][10][11][12] Retrospective analysis of data from the VALUE (Valsartan Antihypertensive Long-term Use Evaluation) trial comparing valsartan-and amlodipine-based antihypertensive treatment reported that early BP control translated into a significant reduction in 5-year CV risk regardless of drug assignment. 13 Definitive studies have not been conducted, however, and the most advantageous time frame for achieving target BP in clinical practice has never been defined.…”

Personalized Hypertension Management in Practice

“…With the knowledge that blood pressure targets are rarely met in those who present with moderate to high blood pressure and that drug side effects become more apparent with increasing dose of single agents, the most logical and practical approach would be low dose combination therapy. This approach has been tested in the STRATHE trial, where introducing low-dose combination therapy, as a first line, appeared superior to sequential monotherapy and stepped care [73]. The STRATHE trial enrolled only patients with mean blood pressures of ≥160 mmHg systolic and ≥95 mmHg diastolic.…”

Newer renin–angiotensin–aldosterone system blocker combinations

“…The BP goal of less than 140/90 mmHg was more easily achieved and maintained in a greater number of patients on low-dose combination therapy (62%) compared to sequential monotherapy (49%) or stepped-care groups (47%). Furthermore, the adverse event rate was much lower in the low-dose combination group [11]. A metaanalysis of 354 randomized trials by Law et al [12] found that a combination of low-dose antihypertensive therapy was superior in achieving a set BP goal and was less likely to have unwanted side effects.…”