Treatment options for hypertension in high-risk patients

Figures & data

Table 1 High risk conditions in hypertension*

Systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg

Diabetes mellitus

Metabolic syndrome

Three or more cardiovascular risk factors

One or more manifestations of subclinical organ damage, eg, left ventricular hypertrophy

Established coronary artery disease

Established cerebrovascular disease

Established peripheral vascular disease

Established chronic kidney disease

Note:

* Adapted from the 2007 European Society of Hypertension and the European Society of Cardiology guidelines for the treatment of arterial hypertension.¹⁰

Table 2 Major clinical trials on the treatment of hypertension for high-risk patients

Trial name	Patients randomized (n)	Characteristics of study population	Drugs	Duration (years)	Primary endpoint
Heart Outcomes Prevention Evaluation (HOPE)^Citation11	9541	Age ≥55 years with one high-risk condition	Ramipril Placebo	4.5	Ramipril 14.0% versus placebo 17.8% (P < 0.001)
Losartan Intervention For Endpoint reduction in hypertension (LIFE)^Citation12	9193	Hypertension and left ventricular hypertrophy	Losartan Atenolol	4.8	Losartan 11.0% versus atenolol 12.8% (P = 0.021)
Anglo-Scandinavian Cardiac Outcome Trial (ASCOT) blood pressure-lowering arm^Citation13	19,257	Hypertension with ≥3 specified risk factors	Amlodipine ± perindopril Atenolol ± bendroflumethiazide-K	5.0	Amlodipine-based 4.5% versus atenolol-based 4.9% (P = 0.105)
Action in Diabetes and Vascular Disease: Preterax and Diamicron-Controlled Evaluation Trial (ADVANCE)^Citation14	11,140	Diabetes mellitus	Perindopril ± indapamide Placebo	4.3	Perindopril + indapamide 15.5% versus placebo 16.8% (P = 0.04)
Ongoing Telmisartan alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET)^Citation15	25,620	High-risk patients with coronary, peripheral arterial, or cerebrovascular disease, or diabetic patients with target organ damage	Ramipril Telmisartan Ramipril + telmisartan	4.7	Ramipril 16.5% versus telmisartan 16.7% versus ramipril + telmisartan 16.3%
Study in ACE Intolerant Subjects with Cardiovascular Disease (TRANSCEND)^Citation16	6666	As ONTARGET study with angiotensin-converting enzyme inhibitor intolerance	Telmisartan Placebo	4.7	Telmisartan 15.7% versus placebo 17.0% (P = 0.22)
Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH)^Citation17	11,506	High-risk hypertensive patients	Benazepril + amlodipine Benazepril + hydrochlorothiazide	3.0	Benazepril + amlodipine 9.6% versus benazepril + hydrochlorothiazide 11.6% (P < 0.001)

ManciaGDe BackerGDominiczakA2007 ESH-ESC Guideline for the management of arterial hypertensionBlood Press20071613513217846925

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The Heart Outcomes Prevention Evaluation Study InvestigatorsEffects of an angiotensin-concerting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patientsN Engl J Med200034214515310639539

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DahlofBDevereuxRBKjeldsenSECardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): A randomized trial against atenololLancet2002359995100311937178

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DahlofBSeverPSPoulterNRPrevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcome Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): A multicenter randomized controlled trialLancet200536689590616154016

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ADVANCE Collaborative GroupEffects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE Trial): A randomized controlled trialLancet200737082984017765963

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The ONTARGET InvestigatorsTelmisartan, ramipril, or both in patients at high risk for vascular eventsN Engl J Med20083581547155918378520

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The TRANSCEND InvestigatorsEffects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: A randomized controlled trialLancet20083721174118318757085

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The ACCOMPLISH Trial InvestigatorsBenazapril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patientsN Engl J Med20083592417242819052124

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