The world of cardiology is still absorbing the implications of the recent landmark trial ACCOMPLISH (Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension). This double-blind randomized controlled trial sought to lower systolic hypertension and prevent cardiovascular (CV) events in high-risk patients. To that end, it measured the efficacy of a single-pill combination of an ACE inhibitor and calcium channel blocker (CCB) vs a single pill combining an ACE inhibitor with the water pill hydrochlorothiazide (HCTZ).

The study population included people ≥ 60 years with one risk factor, and those ≥ 55 with two. The primary outcome measures were CV morbidity and mortality. The ACE/CCB group showed a 21% reduction in CV morbidity and mortality, while both groups showed a significant decrease in systolic blood pressures (BP) as well. BP control rates were still improved for the two groups at three-year follow-up.

Attend to adherence

We already knew that the vast majority of patients will require combination drug therapy, but we can still debate what the best combination strategy is. Recent data suggest that combining lower doses of two antihypertensive agents leads to better compliance and BP control, as well as fewer side effects. Remember, if you aren’t controlling BP, more heart attacks and strokes are taking place. Attention to compliance and adherence is vital. Home BP monitoring leads to greater risk factor modification and success.

Combination therapy should become the norm for most patients with significant hypertension. My current three-drug combination for difficult hypertension includes a diuretic with an ACE or ARB, and a long-acting CCB.

As for choosing between an ACE or an ARB, what research data we have suggests they’re roughly equivalent. We have more data on ACE inhibitors for coronary artery disease, while much of the research on ARBs concerns their effect on kidney function.

ARBs have less of a tendency to cause cough, so in patients who already have a cough, I avoid ACE inhibitors. ARBs are of course more expensive than generic ACE inhibitors, costing about $1.10/day compared to about 40 cents. Branded ACE inhibitors are much closer in price, at about a dollar a day. The generic ACE inhibitor would seem the obvious option for most patients. But there is one caveat: several drug companies making branded antihypertensive drugs offer programs designed to improve BP self-monitoring and make patients more involved in their healthcare. Compliance with medication is notoriously poor in hypertension control, and with some patients, these services may be worth the extra outlay.