Prompt, aggressive BP lowering in high-risk patients

Abstract

Various populations with hypertension have been singled out by current treatment guidelines as requiring more specific treatment. These include patients with stage 2 hypertension, black patients, and patients with coexistent diabetes mellitus and coronary heart disease. Hypertension in these groups is often associated with higher risk of cardiovascular morbidity and mortality. This article reviews current knowledge regarding hypertension in high-risk patient populations, with a particular focus on the importance of prompt, aggressive treatment to lower blood pressure and prevent cardiovascular disease progression. Such treatment includes the early use of multiple-drug therapy with agents that have complementary blood pressure-lowering mechanisms and provide protection from target organ damage. While 2- or 3-drug antihypertensive therapy in these high-risk groups has typically included a diuretic, other combinations of agents may be indicated. Evidence suggests that therapy with a calcium channel blocker and an inhibitor of the renin-angiotensin system is one effective strategy for lowering blood pressure and improving outcomes in these populations.

Figures

Figure 1

Change from baseline in mean sitting systolic blood pressure (SBP) (A) and mean sitting diastolic blood pressure (DBP) (B) in patients with stage 2 hypertension (baseline systolic blood pressure ≥160 mm Hg and/or baseline diastolic blood pressure ≥100 mm Hg). Patients received amlodipine 10 mg, valsartan 160 or 320 mg, combination therapy with amlodipine and valsartan at these same doses, or placebo. Reprinted with permission from Smith et al.48

Figure 2

Change from baseline in mean sitting systolic blood pressure (SBP) (A) and mean sitting diastolic blood pressure (DBP) (B) in black patients treated who received amlodipine 5 mg, valsartan 160 or 320 mg, combination therapy with amlodipine 5 mg plus valsartan 160 or 320 mg, or placebo. Adapted from Smith et al.48

Figure 3

Effects of combination treatment with perindopril plus indapamide vs placebo on deaths and macrovascular and microvascular events in patients with diabetes mellitus in the Action in Diabetes and Vascular Disease: Preterax and Diamicron‐MR Controlled Evaluation (ADVANCE) trial. Black squares indicate point estimates; horizontal lines, 95% confidence intervals (CIs); diamonds, point estimate and 95% CIs for overall effects; vertical broken lines, point estimates for overall effect within categories. Adapted with permission from ADVANCE Collaborative Group.64