Steve Wong, MD, FRCPC (biography and disclosures)
What I did before
Choosing hypertensive agents took into account underlying diagnoses (eg. CHF, hypertension, renal disease, etc) but beyond that, I generally started with thiazide diuretics (due to cost and proven effectiveness) then added either an ACE inhibitor (ACEi) or a calcium channel blocker (CCB), consistent with the Canadian Hypertension Society Guidelines. Most patients will require more than 1 antihypertensive for control. I generally thought as long as BP targets were met, the specific combination was less important.
What changed my practice
There were trials that suggested ACEi + CCB or ARB + diuretic combinations were better than beta-blockers and diuretics (ASCOT BPLA trial, LIFE trial) however controversy remains whether the benefit seen was as a result of less protection from a beta-blocker based regimen. The ACCOMPLISH trial compared a regimen of a CCB+ACEi (amlodipine/benazepril) vs HCTZ/ACEi (benazepril). This 11,500 patient trial was stopped early: although both arms achieved identical BP lowering, the CCB+ACEi arm had 19.6% fewer primary endpoint events (combined cardiovascular mortality, nonfatal MI and nonfatal stroke, hospitalization for angina, revascularization and resuscitated arrest) for an NNT of 45 over 42 months.
What I do now
I would still advocate choosing first and second line agents based on underlying diseases. In absence of this, I still start with a thiazide diuretic in most patients with BP <160/100.
If they are still not controlled, or their drug-naive BP is >160/100 (or >20/10 above target) I would strongly consider changing to or starting off with an CCB/ACEi combination. Obviously there is a higher cost with this, but the results of the ACCOMPLISH trial would support this strategy.References: (Note: Direct article downloads and article requests require a login ID with the BC College of Physicians website)
- ASCOT BPLA: Dahlöf B, Sever PS, Poulter NR, et al. Lancet. 2005;366:895-906.
- LIFE Trial: Dahlöf B et al, Lancet 2002; 359: 995–1003
- ACCOMPLISH: Jamerson et al., N Engl J Med 2008;359:2417-28 (Article Request Form)