Fear of Lowering Cardiovascular Risk by Achieving Blood Pressure Goals: The Irrationality of Combination Therapy Avoidance.

Antihypertensive medication adherence has been the Achilles heel of blood pressure (BP) control for >50 years. While hypertension control rates have improved over the past 2 decades, only a little more than half the people with hypertension are controlled to the goal of <140/90 mm Hg and fewer blacks and Hispanics. This is largely due to poor adherence to medications among other problems. In this issue of Hypertension, Derington et al examined data between 2005 and 2016 from the National Health and Nutrition Examination Surveys to evaluate trends in monotherapy and combination antihypertensive medication use among US adults age ≥20 years with hypertension (n=7837). Survey participants received a detailed in-person home interview, followed by a physical examination including BP measurements at a mobile examination center. The data were analyzed and grouped into 3 cycles, 4-year calendar periods, to provide more stable estimates. Although the proportion of US adults with uncontrolled BP defined as a systolic BP ≥140/90 mm Hg had not changed throughout the 3 consecutive cycles, there was no evidence of changes in the proportions of US adults taking antihypertensive monotherapy or combination therapy. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers were the most prescribed monotherapy within each calendar period followed by diuretics, β-blockers, and calcium channel blockers. The most common combination therapy included an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker with diuretics. However, there was an overall decrease in the proportion of US adults taking a triple therapy regimen. The authors concluded that a large proportion of US adults with hypertension are taking one antihypertensive medication class, urging the need for more effective use of an antihypertensive regimen. The results of the current study continue to add to the already large database demonstrating a failure to follow guidelines consequently resulting in the poor achievement of BP goals as well as failing to optimally reduce cardiovascular risk. In contrast to these analyses, an earlier investigation using the same National Health and Nutrition Examination Surveys database but at a much earlier time period, 20 years earlier, demonstrated an increase in multiple antihypertensive drugs used from 29.1% to 35.8%. Unfortunately, the use of multiple antihypertensive drug classes to reduce cardiovascular risk has not increased over the past decade as evidenced by the current report. The data supporting a role for initial combination therapy to achieve BP goal with fewer side effects compared with increasing monotherapy doses has been available for over 2 decades. Moreover, guidelines dating back to the Joint National Committee 7 report in 2003 and a Consensus Report from the American Society of Hypertension in 2011 support the use of initial combination antihypertensive treatment in those who are 20/10 mm Hg above the BP goal, which today is 130/80 mm Hg. Initial single-pill combination therapy is further emphasized as initial first-line treatment for hypertension in the most recent European Society of Hypertension/Cardiology guidelines as well as reiterated in the American College of Cardiology/American Heart Association guidelines for people who are 20/10 mm Hg above BP goal. Despite these international guideline recommendations, the report by Derington et al demonstrates a failure of health care providers to adhere to guidelines and recommended standards of care, hence, in general, BP control rates have not shown significant improvement. The use of triple combination therapy originated with one of the first cardiovascular outcome trials to treat hypertension in the 1960s. Cardiovascular outcome trials since 2000, regardless of monotherapy randomized to evaluate outcomes, ultimately required 2 or more antihypertensive medications to achieve BP goal. Moreover, the Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension trial is the only trial to randomize 2 different single-pill combinations to evaluate differences in cardiovascular outcomes in over 10 000 participants. In this trial, in addition to the initial single-pill combination medications, most patients required a third medication to achieve BP goal. Medication adherence is a major public health problem since it is the major contributor to failing to achieve BP goals. In 2 separate studies where adherence to BP medications was assessed by checking urine metabolites only 45% of patients were taking their prescribed medications. A recent The opinions expressed in this article are not necessarily those of the American Heart Association. From the Department of Medicine, Am. Heart Assoc. Comprehensive Hypertension Center, University of Chicago Medicine, IL. Correspondence to George Bakris, Department of Medicine, University of Chicago Medicine, 5841 S Maryland Ave, MC 1027, Chicago, IL 60637. Email gbakris@uchicago.edu Fear of Lowering Cardiovascular Risk by Achieving Blood Pressure Goals The Irrationality of Combination Therapy Avoidance