1. Managing Blood Pressure

2. The most rational combinations are represented as thick lines
ESH 2003: Possible Combinations of Different Classes of Antihypertensive Agents
The most rational combinations are represented as thick lines
Diuretics
-blockers
AT1-receptor blockers
This chart shows the following 2-drug combinations that have been found to be effective and well tolerated.54
Diuretic and ACE inhibitor or ARB
Calcium antagonist (DHP) and -blocker
Calcium antagonist and ACE inhibitor or ARB
Calcium antagonist and diuretic
-blocker and -blocker
Other combinations may be used if necessary, and 3 or 4 drugs may be required in many cases.54
-blockers
Calcium antagonists
ACE inhibitors
European Society of Hypertension Guidelines Committee. J Hypertens. 2003;21:
54. European Society of Hypertension Guidelines Committee European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21:
SLIDE 2

3. BP reductions achieved in recent trials
ALLHAT 1
HOPE
PROGRESS
CAPPP
INSIGHT
NORDIL
HOT
STONE
STOP-2
LIFE
ALLHAT 2
ANBP2
INVEST
SCOPE
ASCOT
VALUE
mmHg
mmHg
130
140
150
160
170
180
190
200
SBP 70 80 90
100
110
120
DBP
Mancia and Grassi J.Hypertension 2002 updated

4. RAAS versus Non-RAAS regimens on CV Endpoints
HOPE (n=9,297)
ALLHAT (n=33,357)
LIFE (n=9,193)
VALUE (n=15,245)
ASCOT (n=19,342)
Age (years) 66 67 63
CAD (%) 80 25 16 45 17
Diabetes 39 36 13 33 22
SBP Difference
–3 mmHg office
–3 to –5 mmHg
–1.3 mmHg
–2 to –4 mmHg
–2.9 mmHg
BP advantage
RAAS regimen
Non-RAAS regimen
End point: CV death
–22%
No difference
–13%
–24%
Weir. M, J Clin Hypertens 2006;8:99–105

5. ARB p<0.02 compared with all other classes
Persistence with antihypertensive therapy after 1 and 4 years of treatment
ARB p<0.02 compared with all other classes 10 20 30 40 50 60 70
On treatment (%)
ARB
ACE-I
CCBs
Beta
blockers
Diuretics
1 year
4 years
Content summary: treatment with an ARB results in greater persistent rates of antihypertensive effect over a 4-year period
A total of 15,175 hypertensive patients was included in this study. A linear regression model was designed to test the statistical significance of differences in the percentage of patients persisting on therapy for 4 years for the different antihypertensive classes.
There was a slow continuous decline in persistence in all classes of antihypertensive drugs. A greater percentage of patients treated with an ARB continued treatment during this 4-year period compared with patients treated with ACE inhibitors (50.9% vs. 46.5% at 48 months; p=0.095), calcium antagonists (50.9% vs. 40.7% at 48 months; p<0.03), beta blockers (50.9% vs. 34.7% at 48 months; p<0.03) or thiazide diuretics (50.9% vs. 16.4% at 48 months; p<0.03).
ACE-I: angiotensin converting enzyme inhibitor
ARB: angiotensin receptor blocker
CCB: calcium channel blocker
Reference:
Conlin PR, et al. Clin Ther 2001; 23(12): 1999–2010.
Image:
Reprinted from Clin Ther, Vol 23, Conlin PR, et al., Four-Year persistence patterns among patients initiating therapy with the angiotensin II receptor antagonist losartan versus other artihypertensive drug classes, pages , 2001, with permission from Excerpta Medica Inc.
Conlin PR, et al. Clin Ther 2001; 23(12): 1999–2010.

6. Persistence with different Classes of BP-lowering drugs
Diuretics βB
α-blockers
CCBs
ACE-Is
ARBs
1.83
1.64
1.23
1.08
1.00
0.92
This slide shows that treatment discontinuation has important clinical implications as it may be a major determinant of poor BP control.1
A large cohort study in Lombardia, Italy, assessed the rates and determinants of treatment discontinuation or switching of initial antihypertensive drug therapy in 445,356 subjects aged 40–80 y.1
The figure shows the cause-specific HR for discontinuation using treatment with ACE inhibitors as the reference. The discontinuation rate was lower in patients initially treated with ARBs and higher in patients treated with all other drug classes.1
Discontinuation of the initial single antihypertensive drug treatment was found to be common (cumulative incidence of discontinuation being 33% at 6 months, 41% at 1 y and 50% at 5 y).1
Switching to another monotherapy occurred at lower rates (15%, 17% and 19% at 6 months, 1 y and 5 y, respectively), as did switching a combination therapy (14%, 18% and 25% at 6 months, 1 y and 5 y, respectively).1
Treatment discontinuation rates differed between treatments with different antihypertensive drug classes, the best stay-on treatment rate was observed with blockers of the RAS.1
The maximum discontinuation rates occurred with the initial use of diuretics and βB monotherapy.1
Reference:
Corrao G, et al. Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy. J Hypertens. 2008;26:819–824. - +
0.5
1.0
2.0
Cause-specific HR (95% CI) for discontinuation*
* Relative to ACE-I after 1 y of treatment
Corrrao et al. J Hypertens. 2008;26:819–824.