Australian experts have backed the shift towards more aggressive first-line treatment of hypertension, amid mounting evidence in favour of using combination therapy from day one.
A large, real-world study showed that patients started on more than one antihypertensive had an 11% lower incidence of cardiovascular events over six years compared with those given initial monotherapy.
Those patients who remained on combination therapy throughout the six years had a 26% reduction in cardiovascular events compared with those who only ever took one agent, the study of almost 11,000 newly treated patients in Italy found.
Professor Garry Jennings, director of the Baker IDI Heart and Diabetes Institute in Melbourne, said the findings were in line with the more aggressive strategy advocated by guidelines in Europe and the US.
While combination therapy was not yet indicated in Australia as a first-line treatment, “it was quite likely to happen”, Professor Jennings said.
“What they’re saying really is if you’re going to need more than one drug anyway, you might as well start with that,” he said.
“The use of combination therapy [in general] is so well established in managing hypertension, I think doctors can have great confidence in using it.”
Professor Annemarie Hennessy, foundation chair of medicine at the University of Western Sydney, said evidence emerging in the past year had increasingly supported a shift towards using first-line combination treatments.
“Hitting multiple pathways at the same time, from the theoretical point of view sounds fantastic, and I think we’re all very interested in that,” she said.
However, she cautioned that starting multiple medications at the same time could increase the risk of side effects.
The Italian study involved 10,700 hypertensive patients matched with almost 33,000 controls.
The researchers looked at the use of all available antihypertensive drugs, but did not separately analyse for class effects.
“In daily life practice, a combination of antihypertensive drugs is associated with a great reduction of CV risk,” the study authors wrote in Hypertension.
“The indication for using a combination of blood pressure drugs should be broadened.”