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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ESignificant advances have been made in the recognition and diagnosis of hypertension, but many patients have not achieved blood pressure control at levels that reduce cardiovascular risk. This article discusses the current state of antihypertensive therapy, compliance, and angiotensin receptor blockers.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertensive Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EBlood Pressure Control\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003ESignificant advances have been made in the recognition and diagnosis of hypertension, but many patients have not achieved blood pressure (BP) control at levels that reduce cardiovascular (CV) risk. Marcelo Or\u00edas, MD, Sanatorio Allende, C\u00f3rdoba, Argentina, discussed the current state of antihypertensive therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) [Chobanian AV et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2003] and European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines [\u003Cem\u003EJ Hypertens\u003C\/em\u003E 2003] define hypertension as systolic BP (SBP) of \u2265140 mm Hg and\/or diastolic BP (DBP) of \u226590 mm Hg for an extended time. For individuals with diabetes mellitus, kidney disease, or other high-risk conditions such as stroke or myocardial infarction (MI), the guidelines recommend a target BP of \u0026lt;130\/80 mm Hg.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe Framingham study showed that the relative risk of stroke and coronary heart disease increases as BP increases. Vasan et al. [\u003Cem\u003EN Engl J Med\u003C\/em\u003E 2001] demonstrated increased cumulative incidence of CV events as SBP increases from optimal (\u0026lt;120 mm Hg) to normal (121\u2013129 mm Hg) to high-normal DBP (130\u2013139 mm Hg). In the Hypertension Optimal Treatment [HOT] study, the incidence of major CV events was similar in individuals with DBP \u226480 mm Hg, \u226485 mm Hg, and \u226490 mm Hg but there was a significant difference in the number of major CV events in patients with diabetes with target DBP \u226490 versus \u226485 versus \u226480 (24.4 vs 18.6 vs 11.0 per 1000 patient-years; p=0.005 for trend) [Hansson L et al. \u003Cem\u003ELancet\u003C\/em\u003E 1998].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe Action to Control Cardiovascular Risk in Diabetes [ACCORD] Study Group [N Engl J Med 2010] reported that patients with diabetes receiving intensive antihypertensive therapy had an average SBP of 119.3 mm Hg compared with 133.5 mm Hg in diabetes patients on standard therapy. Most CV outcomes were not significantly different between the 2 groups but stroke was significantly higher in the standard therapy (0.53% per year) versus the intensive therapy group (0.32% per year; HR, 0.59; 95% CI, 0.39 to 0.89; p=0.01). However, evidence of benefit from more active treatment in diabetic patients is inconsistent across trials [ESH\/ESC Guidelines. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EEssential hypertension probably is caused by a combination of mechanisms, some of which are more important in some patients than others. The ESH\/ESC algorithm for treatment of hypertension recommends customizing the choice of therapy to the individual patient and initiating treatment with a low-dose single agent or low-dose combination of 2 agents [ESH\/ESCGuidelines. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2009]. The JNC 7 treatment algorithm recommends lifestyle changes, followed by pharmacologic therapy if BP targets are not reached [Chobanian AV et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2003]. The updated UK National Institute for Clinical Excellence (NICE) recommendations for antihypertensive therapy are shown in \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Updated UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1197072193\u0022 data-figure-caption=\u0022Updated UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12864\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EUpdated UK NICE Guidelines for the Treatment of Newly Diagnosed Hypertension.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EACEI=angiotensin-converting enzyme inhibitors; ARB=angiotensin receptor blockers; CCB=calcium channel blocker. Source: NICE Clinical Guideline 127.2011. \u003Ca href=\u0022http:\/\/www.nice.org.uk\/guidance\/CG12\u0022\u003Ewww.nice.org.uk\/guidance\/CG12\u003C\/a\u003E.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECompliance\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EAnalysis of the third National Health and Nutrition Examination Survey found that of the 41.9 million people in the United States with hypertension, 31% were unaware they had hypertension, 17% were aware but not receiving treatment, 29% were being treated but remained uncontrolled, and 23% who were being treated had achieved control to \u0026lt;140\/90 mm Hg [Hyman DJ \u0026amp; Pavlik VN. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2001]. In persons aged \u226565 years, 45% were unaware of their condition, 32% were aware of their hypertension but were not receiving treatment, and 57% had treated but uncontrolled hypertension.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EHalpern et al. [\u003Cem\u003EJ Hypertens\u003C\/em\u003E 2006] found that patients with increased compliance and persistence with antihypertensive therapy after reaching the BP goal had reduced their predicted relative risk (men, 4.6%; women, 16.4%) and absolute risk (2.1%) of adverse CV outcomes. A retrospective analysis (n=137,277) showed that patients with high adherence (80% to 100%) had a significantly decreased risk of hospitalization (27%) compared to those with compliance of 1% to 19% (44%), 20% to 139% (39%), 40% to 159% (36%), and 60% to 179% (30%) [Sokol MC et al. \u003Cem\u003EMed Care\u003C\/em\u003E 2005]. Another retrospective analysis showed that \u226580% compliant patients used fewer outpatient resources than \u0026lt;80% compliant patients [Halpern \u003Cem\u003EValue Health\u003C\/em\u003E 2005]. Mancia et al. [ESC 1999] showed that 53.3% of patients change their antihypertensive therapy because of adverse effects and 34.1% because their BP was not controlled. Burke et al. [\u003Cem\u003EJ Hypertens\u003C\/em\u003E 2006] found that persistence with antihypertensive therapy substantially declines within the first year of treatment.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAngiotensin Receptor Blockers\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EAngiotensin receptor blockers (ARBs) have been studied extensively. The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial [ONTARGET] investigators randomized 25,620 high-risk patients to telmisartan, ramipril, or telmisartan plus ramipril [ONTARGET Investigators. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008]. The primary composite endpoint of CV death, MI, stroke, or hospitalization for heart failure occurred in 16.5% of the ramipril group and in 16.7% of the telmisartan group, showing that the ARB telmisartan was as effective as angiotensin converting enzyme inhibitor (ACE-I) ramipril for reducing the risk of CV events. Telmisartan was associated with lower rates of cough (1.1% vs 4.2%; p\u0026lt;0.001) and angioedema (0.1% vs 0.3%; p=0.01).\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn the Co-Valsartan Initial Therapy Trial [CDITT], patients treated with valsartan (ARB acting on the AT1 receptor) plus hydrochlorothiazide achieved greater BP control versus those treated with valsartan alone (39.6% vs 21.8%; p\u0026lt;0.0001) [Calhoun DA et al. \u003Cem\u003ECurr Med Opin Res\u003C\/em\u003E 2008]. Jackson et al. [\u003Cem\u003EValue Health\u003C\/em\u003E 2006] showed that patients receiving fixed-dose therapy with valsartan\/hydrochlorothiazide had greater persistence with therapy than those treated with a free combination of valsartan plus hydrochlorothiazide (54% vs 19%; p\u0026lt;0.0001). Studies of amlodipine\/valsartan have shown that appropriate BP reductions occur across all grades of hypertension, with greater decreases as BP severity increases (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Amlodipine\/Valsartan: Appropriate BP Reductions across All Grades of Hypertension.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1197072193\u0022 data-figure-caption=\u0022Amlodipine\/Valsartan: Appropriate BP Reductions across All Grades of Hypertension.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/21\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12865\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EAmlodipine\/Valsartan: Appropriate BP Reductions across All Grades of Hypertension.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EBP=blood pressure; DBP=diastolic blood pressure; HTN=hypertension; SBP=systolic blood pressure; Reproduced with permission from M. Orias, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ECombining a calcium channel blocker (CCB) with an ARB reduces the edema associated with CCBs. The Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension [ACCOMPLISH] trial compared initial therapy with the single-pill combination of a renin-angiotensin-aldosterone system blocker (benazepril) and a CCB (amlodipine) versus benazepril\/hydrochlorothiazide in high-risk hypertensive patients [Jamerson K et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008]. The primary endpoint was the composite of CV morbidity and mortality. This primary event occurred in 552 patients (9.6%) in the benazepril\/amlodipine group versus 679 patients (11.8%) in the benazepril\/hydrochlorothiazide group, for a relative risk reduction of 19.6% (HR, 0.80; 95% CI, 0.72 to 0.90; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EA large proportion of patients require \u0026gt;2 antihypertensive agents to achieve BP control, as shown in the United Kingdom Prospective Diabetes Study [UKPDS; 27% to 31%], Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT; 23%], and ACCOMPLISH (26%) trials [UKPDS. \u003Cem\u003EBMJ\u003C\/em\u003E 1998; Cushman WC et al. \u003Cem\u003EJ Clin Hypertens\u003C\/em\u003E 2008; Jamerson K et al. \u003Cem\u003EBlood Press\u003C\/em\u003E 2007]. Calhoun et al. [\u003Cem\u003EHypertension\u003C\/em\u003E 2009] showed that SBP reductions were greater with triple-combination therapy with amlodipine\/valsartan\/hydrochlorothiazide (\u221239.7 mm Hg) versus valsartan\/hydrochlorothiazide (\u221232.0 mm Hg), amlodipine\/valsartan (\u221233.5 mm Hg), and hydrochlorothiazide\/amlodipine (\u221231.5 mm Hg; p\u0026lt;0.0001). The triple combination was well tolerated, with similar adverse event (AE) rates across all treatment groups (44.9% to 48.3%). AEs were as expected, mostly mild and transient with no indication of target organ toxicity.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EDr. Or\u00edas concluded that AT1 blockers are as potent as and better tolerated than ACE-I. Furthermore, since fixed-dose combination therapy including an AT1 blocker has good compliance, it represents a highly desirable regimen for patients that require more than one antihypertensive agent to achieve their BP goals.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/12\/21.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzncm2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzncm2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}