Blood Pressure Goal Attainment Research Articles

Combination therapy with losartan/hydrochlorothiazide for blood pressure reduction and goal attainment in a real-world clinical setting in Japan

When physicians prescribe a new antihypertensive drug, they do not know the extent of the drug's effect on lowering blood pressure. To resolve this dilemma, a Web-based program was constructed for real-time entry and analysis of treatment. This observational study evaluated the efficacy of losartan/hydrochlorothiazide (Lo/HCTZ) in lowering blood pressure (BP) and achieving BP target values. Physicians prescribed Lo/HCTZ for patients with hypertension who failed to achieve target BP values of < 140/90 mmHg and < 130/80 mmHg in patients with diabetes or chronic kidney disease, respectively, with antihypertensive drugs including an angiotensin receptor blocker. From December 2006 to December 2009, the data of 88,254 patients were entered into this database, and the data of 24,825 subjects were analyzed. At the first visit, a total of 88,254 patients received a first prescription of Lo/HCTZ daily. Among these, at the end of the present analysis, 24,825 (28%) outpatients had a follow-up visit at 1 month and 20,726 (23%) outpatients had a follow-up visit at 6 months. The prevalence of hypertensive patients achieving systolic blood pressure (SBP) control (< 140 mmHg) increased over time from 6.9% to 54.3% in females and 6.1% to 52.3% in males (p < 0.05). At the start of the study, the levels of SBP were significantly highest in the eldest patients (≥ 75 years) followed by the group of 65-75 years and lowest in the youngest patients (≤ 64 years). However, at the end of the study, there were no differences in levels of SBP among the three groups. This Web-based system may provide useful information when a new drug is first released into the market. Treatment with Lo/HCTZ enabled a substantial proportion of hypertensive patients to achieve the recommended goal of < 140/90 mmHg.

Comparative Effectiveness Analysis of Amlodipine/Renin-Angiotensin System Blocker Combinations

A comparative effectiveness analysis of antihypertensive therapy amlodipine (AML) and angiotensin receptor blocker (ARB) fixed- and loose-dose combinations (FDCs and LDCs) in achieving blood pressure (BP) reduction and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) goal attainment was made using retrospective electronic medical record (EMR) data. Treatment goal rates ranged from 35.0% for LDC AML/losartan to 45.7% for FDC AML/olmesartan (OM). FDC AML/OM achieved significantly greater reductions in systolic BP than FDC AML/benazepril (BEN), FDC AML/valsartan (VAL), and LDC AML/ARBs, respectively, and significantly greater reductions in diastolic BP than FDC AML/VAL and LDC therapy, respectively. Compared with patients treated with AML/OM, patients prescribed AML/VAL and LDC AML/ARB were significantly less likely to attain JNC 7 BP goal. Among subpopulations, AML/OM yielded higher rates of goal attainment among both African Americans and obese/overweight patients relative to AML/VAL and combined LDCs. Switchers from monotherapy with AML, OM, or VAL to AML/OM were significantly more likely to attain JNC 7 goals than those switching to AML/VAL or AML/BEN.

Comparison of the Efficacy and Safety of Fixed-Dose Amlodipine/Losartan and Losartan in Hypertensive Patients Inadequately Controlled with Losartan

Fixed-dose combination drugs may enhance blood pressure (BP) goal attainment through complementary effects and reduced side effects, which leads to better compliance. This study aimed to evaluate the efficacy and safety profiles of once-daily combination amlodipine/losartan versus losartan. This was an 8-week, double-blind, multicenter, randomized phase III study conducted in outpatient hospital clinics. Korean patients with essential hypertension inadequately controlled on losartan 100 mg were administered amlodipine/losartan 5 mg/100 mg combination versus losartan 100 mg. The main outcome measures were changes in sitting diastolic blood pressure (DBP) and sitting systolic blood pressure (SBP) and BP response rate from baseline values, which were assessed after 4 and 8 weeks of treatment. Safety and tolerability were also assessed. At week 8, both groups achieved significant reductions from baseline in DBP (11.7 ± 7.0 and 3.2 ± 7.9 mmHg), which was significantly greater in the amlodipine/losartan 5 mg/100 mg combination (n = 70) group (p < 0.0001). Additionally, the amlodipine/losartan 5 mg/100 mg combination group achieved significantly greater reductions in SBP at week 8 and in SBP and DBP at week 4 compared with the losartan 100 mg (n = 72) group (all p < 0.0001). Response rates were significantly higher in the amlodipine/losartan 5 mg/100 mg group versus the losartan 100 mg group (81.4% vs 63.9% at week 4, p < 0.0192; 90.0% vs 66.7% at week 8, p < 0.001). Both treatments were generally well tolerated. Switching to a fixed-dose combination therapy of amlodipine/losartan 5 mg/100 mg was associated with significantly greater reductions in BP and superior achievement of BP goals compared with a maintenance dose of losartan 100 mg in Korean patients with essential hypertension inadequately controlled on losartan 100 mg. Registered at Clinicaltrials.gov as NCT00940680.

Comparison of demographic factors and cardiovascular risk factor control among U.S. adults with type 2 diabetes by insulin treatment classification

AimsData on glucose and cardiovascular disease (CVD) risk factor control among persons with type 2 diabetes mellitus (DM) according to insulin treatment status are lacking. We examined DM control, risk factors, and comorbidities among U.S. persons according to insulin treatment status. MethodsIn the U.S. National Health and Nutrition Examination Surveys 2003–2006, we examined in 10,637 adults aged ≥30 with type 2 DM the extent of control of A1c, LDL-C, HDL-C, triglycerides, and blood pressure (BP) and composite goal attainment by insulin use status. Results6.6% (n=889, projected to 14.3 million) had type 2 DM; of these, 22.9% were insulin users and 57.2% were treated only by other diabetes medications. Overall, 58.2% had an A1c<7% (53 mmol/mol) (insulin users 33.1%, non-insulin treated 66.1%, and 77.9% of those not on medication, p<0.0001). Overall, 44.2% were at a BP goal of <130/80 mmHg, 43.8% had an LDL-C<100 mg/dl (2.6 mmol/L), and 13.9% a BMI<25 kg/m2. Only 10.2% were simultaneously at A1c, LDL, and BP goals (5.4% of those on insulin). ConclusionsU.S. adults with type 2 DM, especially those treated with insulin remain inadequately controlled for A1c and CVD risk factors and have a high prevalence of comorbidities.

Abstract 275: Effect of Customized Cardiovascular Education on Patient Beliefs and Behaviors Around Cardiovascular Medications

Objective: The objective of this project was to describe the effect of tailored cardiovascular (CV) patient education on beliefs and knowledge about medication in a nurse managed CV risk reduction clinic. Methods: This prospective project was conducted on patients 18 years of age or older referred to usual care at a risk reduction clinic. The primary analysis was change in scores on the Beliefs about Medications Questionnaire (BMQ) pre and post customized CV education. Education included a background/risk assessment, personalized general information, disease management education, and therapeutic lifestyle intervention. The BMQ evaluates 2 domains: necessity and concerns about medications; and general overuse and harm of medications. Secondary analysis included pre/post scores on a patient knowledge assessment (2 questions: I have received education on the importance of continuing (1) cholesterol medications and (2) antiplatelet medications) and the relationship between specific demographics and BMQ scores pre/post. A power calculation determined 45 patients were needed. Data were analyzed using paired t-tests. Results Forty-five patients were enrolled and 40 completed the project. Average age was 64 years, 55% were male, and average number of medications was 4.5. Results of the BMQ demonstrated significant improvements in response to the following (scale 1 [strongly disagree] - 5 [strongly agree]): “my medications are a mystery to me” (average score pre=2.7 vs. post=2.2, p&lt;0.05) and medications do more harm than good (average score pre = 2.1 vs. post = 2.0; p&lt;0.05). Scores on all other questions were not significantly different pre/post. A higher number of patients responded “yes” that they were instructed on the importance of continuing cholesterol medications and antiplatelet medications pre/post (p&lt;0.05 for both). Age, gender, and education level did not correlate with BMQ scores pre/post. Patients receiving primary prevention therapies showed significant improvements in score in 4 components of the specific necessity and concerns (p&lt;0.05 for all). In 2 areas of general overuse and harm, there were both increases and decreases in scores, respectively (p&lt;0.05 for all). Patients receiving secondary prevention therapies showed significant changes in scores in 12 components. With regard to specific necessity and concern, scores improved in 4 components (p&lt;0.05 for all). A decrease in perception was seen in 1 component (p&lt;0.05). General overuse and harm scores showed improvements in 5 components (p&lt;0.05 for all). A decrease in perception was seen in 2 components (p&lt;0.05 for all). Conclusions: Customized CV education results in improvements in patients’ beliefs and knowledge about medications. These data have provided a basis to further evaluate education methods in this CV practice. Future implications are to investigate changes in BMQ scores with clinical markers such as LDL and blood pressure goal attainment.

Hypertension in women: latest findings and clinical implications

Cardiovascular disease claims more women's lives than any other disease. Hypertension is an important risk factor for cardiovascular disease in women but is often underestimated and undiagnosed and there is an ongoing misperception that women are at a lower risk of cardiovascular disease than men. The attainment of clinical blood pressure goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive women have uncontrolled blood pressure. Furthermore, there are special risk factors that are unique for women that needs acknowledgement in order to help prevent the great number of hypertension-related events in women. Guidelines for treatment of hypertension are similar for men and women. More studies on the interaction between gender and response to antihypertensive drugs would be of interest.

Abstract P267: A Pharmacist-Led, AHA Heart 360 Supported Home Blood Pressure Monitoring Program Improves Blood Control in Patients With Uncontrolled Hypertension

Objective: Treating hypertension (HTN) reduces morbidity and mortality, yet blood pressure (BP) remains inadequately controlled in a large proportion of patients with HTN. The purpose of this study was to determine if a pharmacist-led home BP monitoring (HBPM) program supported by the American Heart Association's (AHA) Heart 360 website improves BP control for patients with uncontrolled HTN. Methods: This practical randomized controlled study was conducted at Kaiser Permanente Colorado. A total of 353 patients 18 to 85 years of age with uncontrolled HTN, receiving ≤ 3 antihypertensive medications, and with internet access were randomized to the Usual Care (UC, n=174) or the home BP monitoring (HBPM, n=179) group. All patients were seen in clinic at baseline and 6 months for BP measurements. The HBPM group used the AHA Heart 360 website to transmit home BP readings via the internet to clinical pharmacy specialists who made adjustments to patients' antihypertensive medications and/or ordered labs as necessary based on collaborative drug therapy management (CDTM) protocols. The primary endpoint was BP control at 6 months (&lt;130/80 mm Hg for patients with diabetes or chronic kidney disease and &lt;140/90 mm Hg for all others). The number of office, telephone, and email contacts was also compared between groups. Results: Six-month follow-up data were available on 245 patients (245 of 353 (70%)) (n=120 HBPM, n=125 UC). The mean age of the participants was 58 years; 61% were male. There were no significant differences in age or gender between groups. Baseline mean systolic BP was 149 mm Hg in the HBPM group and 145 mm Hg in the UC group (p = 0.08). Rates of 6-month BP control were significantly higher in the HBPM ((58%) 69 of 120) versus the UC group ((38%) 47 of 125) (p &lt; 0.01). The 6-month decrease in systolic BP was larger in the HBPM group (-21 mm Hg) versus the UC group (-9 mm Hg) (p &lt; 0.01). The adjusted relative likelihood of BP goal attainment was 1.5; 95% CI, 1.2 to 2.0. There were no significant differences between groups in the number of office visits; however telephone and email contacts were significantly higher in the HBPM group. Conclusion: A pharmacist-led, HBPM program supported by the AHA Heart 360 website improves BP control for patients with uncontrolled HTN compared to UC.

Abstract P303: Impact of an Employee Health Promotion Program on Cardiovascular Goal Attainment and Cardiovascular Related Medical and Hospital Claims and Costs

CSX Transportation, a national company with 30,000 employees, developed a comprehensive health promotion program to address cardiovascular (CV) disease. High employee CV risk compared to national benchmarks and rising healthcare costs resulted in the need to create the program in 2004. Over time a variety of interventions (ie, biometric screenings, nutrition/exercise health coaching, on-site fitness centers, etc) were implemented at multiple employee locations. An integrated analysis of the impact of the program on goal attainment rates and CV-related medical and hospital claims was completed using 2006 to 2008 data on 5,768 non-union employees. Data integration was completed by linking 3 data sets: biometric results, medical and pharmacy claims. Statistical analysis was completed using Chi Square and Two-Sample T-Tests. In employees with dyslipidemia, mean total cholesterol declined from 196.4 to 185.2 mg/dL (p=0.001), HDL increased from 38.7 to 42.1 mg/dL (p=0.003), and TChol/HDL ratio declined from 5.5 to 4.9 (p&lt;0.001). The percentage of employees reaching LDL goals increased from 48.0% (47/98) to 62.4% (111/178) (p=0.021). In employees with hypertension, mean blood pressure (BP) declined from 137.2/86.1 to 125.4/80.2 mm Hg (p&lt;0.001, for systolic &amp; diastolic). BP goal attainment increased from 42.5% (68/160) to 67.4% (319/473) (p&lt;0.001). In employees with diabetes, mean fasting blood glucose (BG) remained unchanged [129.7 vs 129.6 mg/dL (p=NS)], while non-fasting BG declined from 152.3 to 146.2 mg/dL (p=NS). Analysis of medical claims data for all employees with at least 1 of the 3 conditions revealed reductions in CV-related medical and hospital claims relative to total medical claims. The percentage of employees with a CV-related medical claim declined from 56.6% (1158/2047) to 48.3% (1391/2878) (p&lt;0.001) and CV-related medical claims declined from 14.1% (5479/38770) to 13.1% (6755/51581) (p&lt;0.001). The percentage of employees with a CV-related hospital claim declined from 6.0% (122/2047) to 4.3% (123/2878) (p=0.007) and CV-related hospital claims declined from 2.5% (951/38770) to 1.7% (874/51581) (p&lt;0.001). As a result of the program, CV related medical and hospital costs both declined significantly relative to total medical costs.

Improved Attainment of Blood Pressure and Cholesterol Goals Using Single-Pill Amlodipine/Atorvastatin in African Americans: The CAPABLE Trial

Improved Attainment of Blood Pressure and Cholesterol Goals Using Single-Pill Amlodipine/Atorvastatin in African Americans: The CAPABLE Trial

Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agents in Blood Pressure Management

Background Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk. Objective We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non–ARB-based antihypertensive treatments in a large Canadian primary care database. Methods We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied. Results After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) ( P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) ( P > 0.05), 21% (221 of 1050) on β-blockers ( P = 0.002), and 19% (276 of 1450) on diuretics ( P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non–ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) ( P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%–5.0% for other ARBs; P < 0.02). Conclusions In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.

Trends in utilization of lipid- and blood pressure-lowering agents and goal attainment among the U.S. diabetic population, 1999-2008

BackgroundFor patients with diabetes, clinical practice guidelines recommend treating to a low-density lipoprotein cholesterol (LDL-C) goal of <2.59 mmol/L (100 mg/dL) and a blood pressure (BP) target of <130/80 mmHg. This analysis assessed recent trends in the utilization of lipid-lowering and BP-lowering agents, as well as LDL-C and BP goal attainment, in the U.S. adult diabetic population.Methods9,167 men and nonpregnant women aged ≥20 years were identified from the fasting subsample of the 1999-2008 National Health and Nutritional Examination Survey. Diabetes was identified in 1,214 participants by self report, self-reported use of insulin or oral medications for diabetes, or fasting glucose ≥6.99 mmol/L (126 mg/dL).ResultsThe prevalence of diagnosed or undiagnosed diabetes increased significantly over the past decade, from 7.4% in 1999-2000 to 11.9% in 2007-2008 (P = 0.0007). During this period, the use of lipid-lowering agents by participants with diabetes increased from 19.5% to 42.2% (P < 0.0001), and the proportion at LDL-C goal increased from 29.7% to 54.4% (P < 0.0001). Although there was a significant increase in antihypertensive medication use (from 35.4% to 58.9%; P < 0.0001), there was no significant change in the proportion of participants at BP goal (from 47.6% to 55.1%; P = 0.1333) or prevalence of hypertension (from 66.6% to 74.2%; P = 0.3724).ConclusionsThe proportion of diabetic individuals taking lipid- and BP-lowering agents has increased significantly in recent years. However, while there has been a significant improvement in LDL-C goal attainment, nearly one-half of all U.S. adults with diabetes are not at recommended LDL-C or BP treatment goals.

Olmesartan medoxomil, amlodipine besylate and hydrochlorothiazide triple combination for hypertension

Hypertension is an increasingly prevalent cardiovascular risk factor associated with high rates of morbidity and mortality. Lowering blood pressure (BP) to recommended levels reduces the risk of hypertension-associated cardiovascular events. Despite current treatment options and recommendations, the BP of many patients remains suboptimally controlled. There is a need for more effective management in patients not achieving BP goals on current monotherapy or combination therapy. Regimens combining three or more antihypertensive agents have been shown to increase the proportion of patients achieving BP goals. Recent data suggest that the combination of olmesartan medoxomil, amlodipine and hydrochlorothiazide is a rational treatment option offering safe and effective BP reductions and goal attainment in a greater proportion of patients compared with dual-combination regimens. As the understanding of the importance of BP control grows, treatment options that enable patients to achieve BP goals quickly and safely will become increasingly important in hypertension management.

Valsartan–amlodipine–hydrochlorothiazide: the definitive fixed combination?

A significant proportion of patients with hypertension will need three or more antihypertensive agents to achieve blood pressure goals, particularly those at higher risk. On the other hand, fixed combinations provide an extra beneficial effect, as they improve medication adherence and, secondarily, the attainment of blood pressure goals during follow-up. Triple therapy is recommended in the treatment of hypertension in those patients not adequately controlled with two antihypertensive drugs. In this context, guidelines recommend the combination of a renin–angiotensin system inhibitor, a calcium channel blocker and a diuretic. The triple fixed combination of valsartan–amlodipine–hydrochlorothiazide has been shown to be an effective and safe therapy for treating hypertension and seems a logical approach for those patients uncontrolled with two antihypertensive agents as well as in those patients already treated with three drugs to improve treatment compliance. In this article, available evidence about the efficacy and tolerability of the triple fixed combined therapy valsartan–amlodipine–hydrochlorothiazide for the treatment of hypertension is updated.

Prevalence of High‐Risk Cardiovascular Conditions and the Status of Hypertension Management Among Hypertensive Adults 65 Years and Older in the United States: Analysis of a Primary Care Electronic Medical Records Database

This study compared the prevalence of high-risk cardiovascular (CV) conditions, antihypertensive medication treatment patterns, and demographic and clinical characteristics associated with blood pressure (BP) goal attainment between elderly (65 years and older) and nonelderly (younger than 65 years) adults with hypertension. Retrospective cohort study was conducted using an electronic medical record database among patients receiving at least 1 antihypertensive medication. CV risk profiles were assessed by International Classification of Diseases, 9th Revision diagnosis codes. Treatment patterns were assessed by the number of antihypertensive medications prescribed. BP goal attainment was determined by the mean of the last 2 BP readings during 1 year of follow-up. Logistic regression estimated the odds of achieving BP goal. There were 61,355 nonelderly (mean age, 51.8 years) and 47,796 elderly (mean age, 73.2 years) patients in the study. Elderly patients had statistically significant higher levels of isolated systolic hypertension and complicated hypertension. Elderly patients had statistically significant higher levels of prescribing patterns characterized by multiple antihypertensive medications but statistically significant lower levels of BP goal attainment. Age 65 years and older, African American race, body mass index ≥30, and the presence of complicated hypertension were found to be statistically significant factors contributing to a lower likelihood of BP goal attainment. Despite aggressive antihypertensive treatment, elderly patients are less likely to achieve BP goals.

Predicted Coronary Heart Disease Risk Reduction and Dual Blood Pressure/Cholesterol Goal Attainment in Patients With Hypertension Treated in Real‐World Clinical Practice

Hypertension and dyslipidemia are highly co-prevalent, but often poorly controlled, coronary heart disease (CHD) risk factors. A retrospective cohort study was conducted between January 2004 and April 2008 to compare estimated 10-year CHD risk reduction and dual blood pressure and low-density lipoprotein cholesterol goal attainment (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel III]) in patients with a first prescription for amlodipine monotherapy, co-prescribed amlodipine + statin, or single-pill amlodipine/atorvastatin. In total, 2739 patients were prescribed amlodipine monotherapy, 653 were co-prescribed amlodipine + statin, and 227 were prescribed single-pill amlodipine/atorvastatin. Baseline CHD risk was similar in all 3 cohorts (11.0%-12.5%). Relative CHD risk reduction was greater in those prescribed single-pill amlodipine/atorvastatin (24.5%) compared with amlodipine monotherapy (14.4%, P<.01), and co-prescribed amlodipine + statin (18.4%, P=.01). The findings were driven by greater dual goal attainment for patients prescribed single-pill amlodipine/atorvastatin (50.2%) compared with amlodipine monotherapy (31.7%, P<.05) and co-prescribed amlodipine + statin (37.5%, P<.05).

Critical appraisal of amlodipine and olmesartan medoxomil fixed-dose combination in achieving blood pressure goals

Hypertension remains a significant health burden in the United States, with almost one in three adults affected, and is an independent risk factor for cardiovascular and renal disease. The goal of antihypertensive treatment is to reduce cardiovascular and renal morbidity and mortality by reducing blood pressure (BP). Guidelines recommend a target BP of <140/90 mmHg, with a more stringent goal of <130/80 mmHg for patients with diabetes and chronic renal disease. However, BP goal attainment rates remain low and most patients require therapy with two or more antihypertensive agents. Combination antihypertensive therapy usually employs agents from different classes, thus benefitting from complementary mechanisms of action to achieve greater BP control with fewer side effects. Patient adherence to therapy is enhanced by formulating treatments as fixed-dose (single-pill) combinations. One example is the combination of amlodipine, a dihydropyridine calcium channel blocker (CCB), with olmesartan medoxomil, an angiotensin receptor blocker (ARB). Here, the rationale for the use of CCB/ARB combination therapy is discussed, as well as the pharmacology and tolerability of the amlodipine/olmesartan medoxomil combination and its efficacy in terms of achieving BP goal in patients with hypertension. Advantages of its use from the patient's perspective are also discussed.

‘Multiple action fixed combination. Present or future?’

Cardiovascular disease (CVD) is the most common cause of death in Western countries and will continue to be so in upcoming years. A close correlation has been demonstrated among CVD, stroke, ischemic heart disease, renal failure and a number of modifiable risk factors. As cardiovascular (CV) risk factors commonly co-exist, high-risk patients with hypertension, obesity and diabetes may well benefit from a multiple action combination of CV agents with synergistic efficacy. Control of blood pressure (BP) and the other CV risk factors is still far from the optimal rates and achievement of internationally accepted goals must be imperative. The benefits of achieving these goals, including significant reductions in CV morbidity and mortality, are well documented. Thus, a rigorous effort to improve BP goal attainment is required. Most of the patients will need two or more antihypertensives to achieve BP goal. Administering of two drugs in a single-dose formulation substantially improves patient compliance compared with separate agent administration. Fixed-dose combination therapy can offer potential advantages over individual agents, including increased efficacy, reduced incidence of adverse effects, lower healthcare costs and improved patient compliance through the use of a single medication administered once daily. Currently available fixed-dose agents include several combinations with complementary pharmacodynamic activity. Last, the polypill includes several CV acting agents that affects various CV risk factors and offers encouraging results, although more data are needed to strengthen the polypill concept, its efficacy and safety.

Clinical Inertia and Blood Pressure Goal Attainment

Optimal blood pressure (BP) control is still not being achieved for the majority of patients with hypertension. Although the topic of patient adherence to health care practitioner recommendations is less than desirable and medication noncompliance adds to the cost of health care, another issue that affects the ability to attain optimal BP control is therapeutic, or clinical, inertia, which is the failure of health care providers to initiate or intensify therapy when indicated. This paper will discuss therapeutic inertia and other issues that prevent BP goal attainment.

Trends in hypertension treatment in diabetes

This review discusses current concepts and future trends in the optimal control of elevated blood pressure and hypertension in persons with diabetes, specifically type 2 diabetes mellitus. Although the primary management for persons with type 2 diabetes mellitus, especially with lower levels of blood pressure elevation, is modification or reversal of adverse lifestyles, including weight management and increased physical activity, pharmacologic antihypertensive treatment is usually necessary to optimally control cardiovascular and renal risks. Therapies that modulate the renin-angiotensin-aldosterone system may be beneficial in reducing associated cardiovascular and renal diseases, but control of elevated blood pressure remains an essential target of any antihypertensive therapy. Blood pressure goal attainment, even with pharmacologic therapy, is distressingly low. Certain racial or ethnic groups in the United States have a higher prevalence of diabetes, and greater associated rates of hypertension are noted in African Americans, with increased cardiovascular morbidity and mortality. Clinical evidence may soon confirm or refute the outcomes benefit of blood pressure targets of 120/80 mm Hg or lower.

Amlodipine/Atorvastatin Single‐Pill Therapy for Blood Pressure and Lipid Goals in African Americans: Influence of the Metabolic Syndrome and Type 2 Diabetes Mellitus

African Americans with diabetes +/- the metabolic syndrome are at high risk for cardiovascular disease. This subanalysis of the Clinical Utility of Caduet in Simultaneously Achieving Blood Pressure and Lipid End Points (CAPABLE) trial studied attainment of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) goals by 8 flexibly titrated doses (5/10-10/80 mg) of amlodipine/atorvastatin single pill in 494 African Americans with hypertension and dyslipidemia, according to the presence of diabetes +/- the metabolic syndrome. In 169 diabetic patients, the metabolic syndrome was associated with poorer BP goal attainment (38.5% vs 48.5% in diabetic patients without the metabolic syndrome). Among diabetic patients (+/- the metabolic syndrome) 61% to 62% reached LDL-C goal. More than 60% of patients with diabetes uncontrolled for LDL-C were maintained on suboptimal atorvastatin therapy (mean final dose: 29.9 mg vs maximum of 80 mg). Reluctance to intensify therapy to attain accepted targets in high-risk individuals suggests a degree of clinical inertia not explained by objective evidence of dose-dependent intolerance.