Is amlodipine the best initial monotherapy for hypertension?

Combination therapy in hypertension: what are the best options according to clinical pharmacology principles and controlled clinical trial evidence?

Despite extensive debate about the first choice for treating essential hypertension, monotherapy effectively normalizes blood pressure (BP) values in only a limited number of hypertensive patients. Thus, the aim of combination therapy should always be to both improve BP control and to reduce cardiovascular events. Antihypertensive drugs can be effectively combined if they have different and complementary mechanisms of action. This is crucial to obtain additive BP-lowering effects without impacting on tolerability. One typical combination is the association of drugs blocking and stimulating the renin-angiotensin system (RAS) (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker and calcium antagonist or diuretic, respectively). In contrast, some combinations (e.g., calcium antagonists plus diuretics or beta-blockers plus RAS blockers) have no additive BP-lowering effects, while other combinations (e.g., clonidine plus alpha-1 receptor blockers) can have a negative interaction. Regardless, BP reduction is not the only mechanism that reduces cardiovascular risk. Scientific evidence indicates that some drug classes are better than others in this respect, and therefore some drug combinations are also better than others. The results of the ASCOT-BPLA and ACCOMPLISH trials suggested that an ACE inhibitor/calcium antagonist combination had better cardioprotective effects than beta-blocker/diuretic or ACE inhibitor/diuretic combinations. It is worth noting that no controlled clinical trials have used hard endpoints when investigating the effects of an angiotensin receptor blocker/calcium antagonist combination. In conclusion, combination therapy is needed for optimal antihypertensive management, with the first choice being an ACE inhibitor plus a calcium antagonist. This approach should improve BP control and provide better cardiovascular protection.

Optimizing the treatment of hypertension and stable coronary artery disease: clinical evidence for fixed-combination perindopril/amlodipine

BACKGROUND

Optimized management of hypertension and coronary artery disease (CAD) improves cardiovascular risk and outcomes, and prevents complications. This article reviews evidence for the fixed combination of the angiotensin-converting enzyme (ACE) inhibitor perindopril and the calcium channel blocker amlodipine.

METHODS

A literature search was performed in PubMed/MEDLINE to identify articles published in English between 1988 and March 2008 describing clinical trials, particularly outcome trials, or mechanisms of therapeutic action relevant to the use of combination therapy in patients with hypertension or stable coronary artery disease with an ACE inhibitor (perindopril) and a calcium channel blocker (amlodipine).

FINDINGS

Clinical trials indicate that this combination may have a positive impact on cardiovascular mortality and morbidity in hypertensive individuals. The two complementary mechanisms of action appear to work in synergy, leading to more efficient blood pressure lowering, improved fibrinolytic function, and reduction of secondary effects. This also represents a simplified management strategy for stable CAD. Perindopril has proven efficacy in the prevention of cardiovascular events and mortality in CAD patients, while amlodipine is widely used in the symptomatic management of CAD. Both aspects of guideline-recommended management of CAD are therefore addressed in a single tablet.

CONCLUSIONS

The clinical evidence for fixed-combination perindopril/amlodipine indicates it as a credible option for the optimization of the management of hypertension and CAD.