Expedited blood pressure control with initial angiotensin II antagonist/diuretic therapy compared with stepped-care therapy in patients with ambulatory systolic hypertension

Effectiveness of initiating treatment with valsartan/hydrochlorothiazide in patients with stage-1 or stage-2 hypertension

This prospective, 6-week, multicenter, double-blind study examined the benefits of initiating treatment with combination valsartan/hydrochlorothiazide (HCTZ) compared with initial valsartan monotherapy for 648 patients with stage-1 or stage-2 hypertension (age=52.6±10 years; 54% male; baseline blood pressure (BP)=161/98 mm Hg, 32% stage 1). Patients were randomized to valsartan 80 mg (V-low), valsartan 160 mg (V-high) or valsartan/HCTZ 160/12.5 mg (V/HCTZ), and electively titrated after weeks 2 and 4 to the next dosage level (maximum dose valsartan/HCTZ 160/25 mg) if BP remained >140/90 mm Hg. At end of the study, patients initiated with V/HCTZ required less titration steps compared with the initial valsartan monotherapy groups (63 vs 86% required titration by study end, respectively) and reached the target BP goal of <140/90 mm Hg in a shorter period of time (2.8 weeks) (P<0.0001) vs V-low (4.3 weeks) and V-high (3.9 weeks). Initial combination therapy was also associated with higher BP control rates and greater reductions in both systolic and diastolic BP from baseline (63%, −27.7±13/–15.1±8 mm Hg) compared with V-low (46%, −21.2±13/−11.4±8 mm Hg, P<0.0001) or V-high (51%, −24.0±13/−12.0±10 mm Hg, P<0.01). Overall and drug-related AEs were mild to moderate and were similar between V/HCTZ (53.1 and 14.1%, respectively) and the two monotherapy groups, V-low (50.5 and 13.8%) and V-high (50.7 and 11.8%). In conclusion, initiating therapy with a combination of valsartan and low-dose HCTZ results in early, improved BP efficacy with similar tolerability as compared with starting treatment with a low or higher dose of valsartan for patients with stage-1 and stage-2 hypertension.

Blood pressure responder rates versus goal rates: which metric matters?

Reducing blood pressure (BP) to guideline-recommended goals associated with reductions in cardiovascular risk is central to effective hypertension management. In addition to measuring BP reduction, clinical trials of antihypertensive agents should assess the percentage of patients responding to treatment. The Food and Drug Administration's defined rate of response required for drug approval is a reduction in diastolic BP (DBP) to <90 mmHg and/or a DBP reduction of > or = 10 mmHg. Consequently, some patients may be counted as responders even if they have not reached DBP <90 mmHg. An antihypertensive agent's effectiveness may be better assessed by the proportion of patients who achieve recommended BP goals. This article analyzes the frequency of response rates versus goal rates as endpoints in randomized trials since January 2001. Data showed that goal rates, especially combined systolic BP (SBP)/DBP goal rates, are consistently lower than response rates in studies evaluating both endpoints. Goal rates incorporating both SBP and DBP, or having a focus on SBP for individuals >50 years of age, provide the most clinically relevant information and are a more clinically relevant metric of an agent's ability to reduce BP than DBP alone.