Saturday, May 18, 1:30 AM – 3.30 AM: Combination drug therapy for high-risk hypertensive patients: Combination drug therapy for high-risk hypertensive patients

Abstract

The primary rationale for combination therapy is to enhance blood pressure control by using drugs that have an additive effect (e.g. diuretics and beta-blockers or calcium antagonists and converting enzyme inhibitors). However, complicated and sometimes costly drug regimens can result in noncompliance and the risk of adverse events increases with the use of high doses of these drug combinations. Fortunately, new fixed-dose combination antihypertensive drugs can improve compliance by simplifying dosing regimens and decreasing dose-dependent side effects, thus improving blood pressure control while reducing cost.

Awareness and treatment of hypertension in the United States has been growing among three high-risk groups: African Americans, patients with type II diabetes mellitus, and those with chronic renal insufficiency. Despite advances in treatment, however, hypertension continues to be poorly controlled in many patients. The blood pressure goal for patients with type II diabetes mellitus is a systolic <130mmHg and diastolic <80mmHg. If gross proteinuria is present, then a tighter range is recommended. However, actual attained control rates are low, despite potent data documenting the reduction of cardiovascular events by treating diastolic hypertension and isolated systolic hypertension. New data show a reduction in the progression of renal insufficiency with angiotensin receptor blockers and an actual reduction in total and cardiovascular mortality with angiotensin converting enzyme inhibitors. There are no outcome data to determine which combination of drugs optimizes nephroprotection and cardioprotection, but it is suspected that angiotensin converting enzyme inhibitors with nondihydropyridines may be optimal.

African Americans have a disproportionate number of risk factors, including diabetes mellitus, left ventricular hypertrophy, obesity, and decreased leisure-time physical activity. In addition, congestive heart failure, sudden cardiac death, acute coronary ischemia, stroke, and renal insufficiency are more common in blacks than whites. Thus, target blood pressure for African Americans should be similar to that set for patients with type II diabetes mellitus. In blacks with renal insufficiency, angiotensin converting enzyme inhibitors are superior to beta-blockers or dihydropyridine calcium channel blockers. More outcome data are needed to confirm the optimal combination of drugs that are vascular-protective.