Expedited blood pressure control with initial angiotensin II antagonist/diuretic therapy compared with stepped-care therapy in patients with ambulatory systolic hypertension

• Published in: Canadian journal of cardiology Vol. 23; no. 5; pp. 377 - 382
• Main Authors: Lacourcière, Yves, MD, Poirier, Luc, BPharm MSc, Lefebvre, Jean, BPharm MSc
• Format: Journal Article
• Language: English
• Published: England Elsevier Inc 01-04-2007; Pulsus Group Inc
• Subjects: Aged; Angiotensin II Type 1 Receptor Blockers - therapeutic use; Antihypertensive Agents - therapeutic use; Antihypertensive therapy; Cardiovascular; Clinical Studies; Diuretics - therapeutic use; Drug Therapy, Combination; Female; Humans; Hydrochlorothiazide; Hydrochlorothiazide - therapeutic use; Hypertension; Hypertension - drug therapy; Initial combination therapy; Losartan; Losartan - therapeutic use; Male; Middle Aged; Treatment Outcome; Antihypertensive therapy; Hypertension; Hydrochlorothiazide; Initial combination therapy; Losartan
• ISSN: 0828-282X; 1916-7075
• DOI: 10.1016/S0828-282X(07)70771-7

Objectives The present study investigated whether initiating therapy with a combination of losartan (L) and hydrochlorothiazide (HCTZ) allows for faster blood pressure (BP) control and fewer medications than the usual stepped-care approach in patients with stage 2 or 3 hypertension and ambulatory systolic hypertension. Methods : Patients with a mean daytime systolic ambulatory BP (ABP) of 135 mmHg or higher were randomly assigned to receive L 50 mg plus HCTZ 12.5 mg titrated to L 100 mg plus HCTZ 25 mg versus HCTZ 12.5 mg plus atenolol 50 mg. Amlodipine 5 mg was then added, if needed, to achieve a BP goal of less than 130 mmHg. Treatment titration was based on ABP. Results Significantly more patients randomly assigned to L/HCTZ (63.5%) than stepped-care (37.5%; P = 0.008) achieved the primary end point (daytime systolic BP of less than 130 mmHg). Initial L/HCTZ induced significantly greater decreases in ABP during each 24 h period after six weeks of therapy. Although reductions in systolic and diastolic ABP were not statistically different at the end of the study, ABP reduction was significantly greater (P<0.001) with the L/HCTZ-based regimen. Twice as many patients in the L/HCTZ group achieved the goal ABP with no more than two drugs (30.0% versus 14.7%; P = 0.03). Moreover, tolerability was significantly better (P = 0.006) in the L/HCTZ group, with a 40.0% incidence of adverse events, versus 65.6% in the stepped-care group. Conclusion Initiating antihypertensive therapy with the combination of L/HCTZ in patients with stage 2 or 3 hypertension and ambulatory systolic hypertension reaches a target BP faster in a higher proportion of patients, with fewer adverse events and less need for a third drug regimen than the conventional stepped-care approach.