Study IDs Superior Two-drug Antihypertensive Regimen in sub-Saharan African Patients

Studies suggest that most patients with hypertension (HTN) require dual antihypertensive therapy to reach target blood pressure goals. Blacks are at particularly high risk for HTN, but the most effective dual antihypertensive therapy in this population has not been established.

A new study published in the New England Journal of Medicine suggests that amlodipine combined with hydrochlorothiazide (HCTZ) or perindopril is more effective vs perindopril plus HCTZ for lowering blood pressure in black patients from sub-Saharan Africa.¹

The randomized controlled trial included 728 patients with uncontrolled HTN (≥140/90 mm Hg while untreated or on antihypertensive monotherapy) and was conducted at 10 centers in 6 countries in sub-Saharan Africa.

Participants (mean age 51 years, 63% women) were randomized to a daily dose of amlodipine 5 mg plus HCTZ 12.5 mg; amlodipine 5 mg plus perindopril 4 mg; or, perindopril 4 mg plus HCT 12.5 mg. All doses were doubled at 2 months to reach target doses.

Results showed that the primary endpoint-change in 24-hour ambulatory systolic blood pressure (SBP) from baseline to 6 months-was significantly lower with amlodipine-HCTZ and with amlodipine-perindopril than with perindopril-HCTZ. Reductions were similar for amlodipine-HCTZ and amlodipine-perindopril.

Differential effects were similarly seen on office and ambulatory diastolic blood pressure, blood-pressure control, and treatment response rates among the 3 treatment groups. 

All analyses were adjusted for age, sex, trial site, baseline SBP, diabetes (DM), dyslipidemia, body mass index, heart rate, and duration of HTN.

Authors note that a long-acting dihydropyridine calcium-channel blocker (CCB) like amlodipine may be a critical component of dual antihypertensive therapy in black patients from sub-Saharan Africa.

Results contrast with US guideline recommendations (CCB or a diuretic added to a different drug class),² and European guideline recommendations (CCB plus a diuretic or an ACE inhibitor, or an ACE inhibitor plus a diuretic).³

Results may not generalize to blacks with DM, individuals outside sub-Saharan Africa, thiazide-like diuretics or other agents in the same drug class.

REFERENCES:
1. Ojji DB, Mayosi B, Francis V, et al. Comparisons of dual therapies for lowering blood pressure in black Africans [published ahead of print March 18, 2019]. N Engl J Med. doi: 10.1056/NEJMoa1901113.
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:2199-2269.
3. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021-3104.