Compared with current hypertension management approaches, a straightforward algorithm featuring fixed-dose combination therapy leads to superior blood pressure (BP) control, according to findings of a new randomized trial.

Several influences – failure to meet BP targets, inadequate patient counseling and follow-up, and increasingly complex hypertension treatment algorithms – have led to “therapeutic inertia” in hypertension control among healthcare providers, said Ross D. Feldman, MD, Robarts Research Institute, London, Ontario, Canada. The Simplified Treatment Intervention to Control Hypertension (STITCH) trial evaluated an algorithm designed for use in the family practice setting to combat the growing “epidemic” of nonadherence to guideline-based antihypertensive regimens.

The STITCH trial included 45 practices treating 2,104 patients in southwestern Ontario, Canada. Practices were randomly assigned to implement the Canadian Hypertension Education Program (CHEP) (n=27) or STITCH (n=18) treatment algorithm for the management of hypertension. The STITCH algorithm featured four steps:

• Initiate treatment with one-half tablet of the lowest dose of a fixed-dose combination

  • - Angiotensin-converting enzyme-inhibitor (ACE-I)/diuretic or angiotensin-receptor blocker (ARB)/diuretic

• Increase the combination dose

  • - Instruct patients to take the full tablet, then up-titrate to higher fixed doses

• Add a calcium channel blocker

• Add an alpha-blocker, beta-blocker, or spironolactone

The primary endpoint was the proportion of patients who were treated to target BP levels: <140/90 mm Hg and <130/80 mm Hg for patients with and without diabetes, respectively. At 6 months, significantly more patients in the STITCH group (64.8%) than in the CHEP group (52.7%) achieved BP targets (p=0.026). This represents an absolute benefit of 12% in favor of the STITCH algorithm (95% CI, 1.5–22.4%).

Systolic and diastolic BP levels improved in both groups, though the improvement was significantly greater among patients treated according to the STITCH practices. In the STITCH and CHEP groups, systolic BP dropped by 23 mm Hg and 18 mm Hg, respectively (p=0.002), whereas diastolic BP fell by 10 mm Hg and 8 mm Hg, respectively (p=0.03).

In practices assigned to the STITCH protocol, physicians were able to implement fixed-dose combination therapy in the majority (85%) of patients. By comparison, only 15% of patients in the CHEP group were treated with fixed-dose combination therapy (p<0.001).

“This simplified approach, which can be taught and used in busy family practices, resulted in better blood pressure control with less overall drug use,” Prof. Feldman concluded. “The STITCH protocol may be a paradigm for the management of a range of chronic diseases that show poor control rates.”