Applying the Strategy of Combination Antihypertensive Therapy to Special Populations

The relationship of blood pressure (BP) to cardiovascular risk is linear, positive, and continuous, at least to levels of 115/75 mm Hg. ¹ Moreover, long‐term observational and interventional studies have demonstrated that reduction of elevated BP reduces the risk of clinical complications such as myocardial infarction, stroke, heart failure, and renal disease. Based on accumulating evidence from clinical trials, BP goals in recent policy guidelines for the treatment of hypertension continue to be lowered: <140/90 mm Hg for the general population with uncomplicated hypertension and <130/80 mm Hg for patients with diabetes or renal disease. ² , ³ , ⁴ Reducing BP is a challenge in patients with BP above these levels, and most will need multiple antihypertensive medications to achieve satisfactory results. In fact, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) ² encourages physicians to consider initiating antihypertensive therapy with a combination of two or more agents, as separate prescriptions or in fixed combination, for patients whose BP is >20 mm Hg systolic or >10 mm Hg diastolic above goal. The International Society on Hypertension in Blacks (ISHIB) ³ endorses a similar policy for patients whose BP is ≥15/10 mm Hg above goal.

Despite guideline recommendations, only about one third of adults with hypertension in the United States receive sufficient therapy to attain a BP of <140/90 mm Hg. ⁵ Control rates are particularly poor among individuals with diabetes, with only one quarter achieving their BP goal. ⁵ There is a considerable opportunity to increase levels of BP control and substantially reduce cardiovascular and renal morbidity and mortality with the appropriate utilization of currently available treatment options, including greater use of combination therapy.

The purpose of this supplement to The Journal of Clinical Hypertension is to review the place of multidrug therapy in improving BP control in the general population and in selected patient groups within the context of current management guidelines. In the first article, Elizabeth O. Ofili, MD, MPH, explores various misperceptions regarding the use of antihypertensive combination therapy in general practice. Dr. Ofili explains that once‐daily, fixed‐dose combinations of well tolerated drugs with complementary mechanisms of action provide a safe, efficacious, and cost‐effective approach to BP goal attainment in a broad range of patients and encourage patient adherence to the treatment regimen.

Increased BP is one of the most common, yet modifiable, components of the cardiometabolic syndrome. In the second article, Camila M. Manrique, MD, and colleagues consider the importance of BP control and the therapeutic options for achieving it in patients with the cardiometabolic syndrome through lifestyle modifications and appropriate drug therapy. Since the prevalence of the cardiometabolic syndrome is expected to increase in coming years in parallel with the projected increase in the prevalence of obesity, successfully reducing BP to goal in these patients should translate into immense public health benefits by preventing future morbidity and mortality.

The third article, by Keith C. Ferdinand, MD, and Elijah Saunders, MD, addresses issues specific to the management of hypertension in the African‐American population. This paper emphasizes the high prevalence of hypertension and high degree of associated morbidity and mortality in African‐American patients. It also reviews the clinical trial data demonstrating the benefits of BP control in African Americans, and summarizes JNC 7 and ISHIB treatment recommendations relating to this ethnic group. ² , ³

In the final article, Dr. Saunders focuses on the need to improve long‐term BP control among patients who have survived an acute myocardial infarction or stroke, to reduce their risk of a second event. Although these patients may be discharged from the hospital on antihypertensive therapy, the treatment may not be sufficient to reduce BP to goal. Subsequent careful titration of antihypertensive treatment by the primary care physician, as part of a secondary cardiovascular disease prevention program, should enable a BP goal of <140/90 mm Hg to be achieved in most patients.

The definition of hypertension continues to evolve. ⁶ It is likely that future recommendations for the treatment of hypertension will focus on lower levels of BP, with an emphasis on total cardiovascular risk. The ability of the physician to utilize appropriate combinations of pharmacologic agents for achieving optimal vascular health will be tested.