ESC Congress 2017 In Review -- Main Edition - 15A

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Sponsored Session Highlights
Management of Hypertension,
Ischaemic Heart Disease, and
Heart Failure Throughout the
Cardiovascular Disease Continuum
Management of Hypertension
Although the appropriate management of hypertension
is growing steadily, the result is far from optimal, mainly
due to the complexity of the disease, poor adherence
to treatment, and physicians' inertia. Guiseppe Mancia,
MD, University of Milano, Milano, Italy, Stéphane Laurent,
MD, PhD, Université Paris Descartes, Paris, France, and
Krzysztof Narkiewicz, MD, Medical University, Gdansk,
Poland, explored the issues involved in initiating antihypertensive treatment with monotherapy or single-pill
combination (SPC) therapy.
The 2013 ESH/ESC hypertension guidelines recommend initial monotherapy for patients at lower risk of
cardiovascular (CV) disease and a 2-drug combination
for those at higher risk (Figure 1).1
Figure 1. 2013 ESH/ESC Hypertension Guidelines: Monotherapy vs
Drug Combination Strategies to Achieve Target Blood Pressure

Mild BP elevation
Low/moderate
CV Risk

Choose between

Single agent

Switch to
different agent

Full dose
monotherapy

Marked BP elevation (IIb C)
High/very high
CV Risk
Two-drug combination

Previous agent
at full dose

Previous combination
at full dose

Add a
third drug

Two drug
combination
at full dose

Switch to
different two-drug
combination

Three-drug
combination
at full dose

Moving from a less intensive to a more intensive therapeutic strategy
should be done whenever BP target is not achieved.
BP, blood pressure; CV, cardiovascular.
Adapted from Mancia G et al. J Hypertens. 2013;31:1281-357.

For successful hypertension treatment, the following
criteria must be met: controls both office and 24-hour
blood pressure (BP); has good tolerability; leads to better
compliance; and reduces CV risk. The traditional approach
of initiating with monotherapy controls office BP but is
inconsistent with respect to the other criteria. According to
Dr Laurent, the advantages of initiating with 2-drug combination therapy include greater efficacy and fewer side
effects, more rapid antihypertensive response, and a greater probability of achieving the target BP. Disadvantages of
initial 2-drug combinations include prescribing an unnec-

essary second drug in some patients, risk of hypotension,
and lack of testing against monotherapy in randomised
trials.2 However, results of several observational trials suggest that initial combination therapy is more effective for
lowering BP and improving CV outcomes.3-7
The disadvantages could be overcome by using a
tailored, effective combined dose and slowly escalating
therapy. A study comparing classical stepcare monotherapy (irbesartan plus hydrochlorothiazide) with a
4-step tailored effective combined dose strategy (perindopril/amlodipine) reported greater BP reductions and
fewer adverse outcomes with combination therapy.8
BP is not controlled over 24 hours in about 75% of
hypertensive patients. Dr Narkiewicz argued that longacting SPCs with a long duration and high trough-to-peak
ratio are more likely to provide 24-hour BP control than
monotherapy. The evidence shows that SPCs improve
tolerability. In an analysis of 25 trials, a calcium channel
blocker (CCB)/renin-angiotensin system blocker combination reduced the risk of CCB-associated peripheral oedema
compared with CCB monotherapy (RR, 0.62; 95% CI, 0.53
to 0.74; P < .00001).9 Another study showed that adherence to therapy improved in patients switched from freedrug combinations to the corresponding SPCs of the same
drugs.10
In a comparison of amlodipine and perindopril given
as an SPC vs 2-pill combination, the SPC was associated
with superior persistence (42 vs 7 months) and reduced
mortality (8% vs 18%).11
Dr Mancia commented that initial 2-drug combination therapy should be more strongly supported by the
guidelines. The evidence supports initiation of 2-drug
combination therapy in all hypertensive patients.
Therapy with SPCs based on long-acting drugs tested
in clinical trials is a preferred choice for hypertension
management, particularly for providing 24-hour control
in patients with masked hypertension.
Optimal Medical Therapy in Ischaemic
Heart Disease
Angina and coronary artery disease (CAD) are complex
multifactorial syndromes. According to Carl J. Pepine,
MD, University of Florida, Gainesville, Florida, USA, angina is under-recognised and undertreated. Many trials
have compared coronary revascularisation with optimal medical therapy (OMT), including single studies and
large meta-analyses. Over very long follow-up periods
and very large sample sizes, no study or meta-analysis
showed that revascularisation influences death or most
other outcomes. Only the MASS II study suggests a benefit in the occurrence of nonfatal myocardial infarction,
usually related to coronary artery bypass graft (CABG).
An extensive meta-analysis of 64,905 patients
showed an increase in risk of 2- to 3-fold associated

This peer-reviewed article was based on scientific-clinical content presented at the ESC (European Society of Cardiology) Congress 2017. The content of this article
was entirely developed by Content Ed Net Medicom, and the opinions expressed herein do not necessarily represent those of the European Society of Cardiology, nor
of SERVIER. The development of this article was supported by SERVIER. This material is intended for educational purposes.

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