Initial hypertension treatment: one combination fits most?

The absolute number of patients with uncontrolled hypertension is growing worldwide. Many factors may be involved, including physician inertia and patient nonadherence. In this context, we reviewed published studies related to the efficacy and efficiency of starting combination antihypertensive treatment versus mono-therapy. The overall evidence supports that initial combination therapy is more effective for many outcomes (ie, reaching blood pressure targets, rapidity of control, patient adherence, and cardiovascular protection assessed by surrogate markers). The few available published clinical trials and observational studies support that the amlodipine + an angiotensin-converting enzyme inhibitor combination may be the most effective for reducing cardiovascular events. We outline a novel algorithm of starting initial therapy with a single tablet containing amlodipine + benazepril in most patients with hypertension regardless of stage or comorbidities. It is our hypothesis that this streamlined approach is likely to yield an overall positive risk/benefit ratio and that it should be tested in an outcome trial versus accepted monotherapies in stage I hypertension.