The Use of Combination Drug Therapy in the Treatment of Hypertension

Prog Cardiovasc Nurs. 2002;17(2) 

In This Article

Abstract and Introduction

Data from the National Health and Nutritional Examination Survey and from the World Health Organization have clearly demonstrated that, worldwide, less than one quarter of hypertensive patients are adequately controlled by our currently accepted blood pressure (BP) goals. These patients remain at significant risk for the development of cardiovascular disease. Although, there are multiple reasons contributing to inadequate blood pressure control, the most important include: 1) patient compliance; 2) acceptance of inadequate BP control by clinicians; 3) lower BP goals; and 4) the fact that it is very difficult or impossible to achieve adequate BP control with monotherapy in the majority of patients. The use of combination therapy, either as first-line treatment or much earlier in the course of treating hypertensive patients, may provide the solution to many of these management problems. Low-dose combination therapy provides several advantages in that: 1) it will be more effective than monotherapy due to the additive effect on BP of complementary drugs; 2) it will provide 24-hour efficacy with once-a-day dosing since most of the low-dose combination drugs include long-acting components; 3) it will have a higher response rate than monotherapy and will be effective in most subgroups of hypertensive patients due to the complementary nature of combination therapy; 4) it may have fewer metabolic side effects than higher dose monotherapy since metabolic side effects also tend to be dose dependent; 5) it may have fewer dose-dependent side effects than monotherapy, as BP control is obtained at lower doses of each of the component drugs; 6) it is more convenient than monotherapy; 7) it may cost less, since low-dose combination therapy tends to be a little more expensive than each of the components but cheaper than if each of the components were used separately. For these reasons, the use of low-dose combination therapy as first-line treatment or much earlier in the stepped-care approach may play a major role in improving the dismal control rates in hypertensive patients, which may ultimately have a positive impact on the rate of development of cardiovascular disease.

Hypertension is associated with increased risk of developing strokes and heart attacks. As a result, the primary goal in the management of hypertension has always been a reduction in the incidence of cardiovascular events in hypertensive patients. Meta-analyses of studies performed to assess the impact of treating hypertension on the incidence of cardiovascular disease have revealed impressive reductions in the incidence of strokes amongst hypertensive patients, but very disappointing reductions in the incidence of coronary artery disease (CAD).[1,2] Moreover, the rates of congestive heart failure (Figure 1) and end-stage renal failure (Figure 2) amongst hypertensive patients have steadily increased during the past 10 years.[3]

Prevalence of congestive heart failure by age, 1976-1980 and 1988-1991

Incidence rates per million population of reported end-stage renal disease therapy, 1982-1995

These findings necessitate changes in the approach to the management of hypertensive patients in an effort to have a greater impact on the incidence of CAD. There are undoubtedly several reasons for the poor reductions in CAD; however, a more aggressive approach to the early management of hypertension may be the single most important change necessary to impact the incidence of CAD.

The purpose of this manuscript is to discuss the earlier use of low-dose combination therapy in the management of hypertension and to assess if this change in the approach to hypertension may ultimately provide the solutions to some of the problems we face in hypertension.