SF | CARDIOLOGY
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October 2021 | Vol. 21 No. 10 www.medicalacademic.co.za
This article was independently sourced by Specialist Forum.
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Fixed-dose combination therapy in HYPERTENSION HYPERTENSION
An estimated 1.4 billion people worldwide have hypertension, but only 14% have it under control. In South Africa more than 90% of patients with hypertension are uncontrolled primarily due to a lack of awareness about their condition, and access to treatment.1,2
H
ypertension is a major risk factor for cardiovascular disease (CVD). More people die annually from CVDs than any other cause. An estimated 60% of CVD- and stroke-related deaths occur in low- and middle-income countries. Delay of treatment is particularly concerning since it can lead to losing the patient for follow up, potentially resulting in adverse CV outcomes.1
When to initiate antihypertensive treatment The 2021 World Health Organization (WHO) guideline for the treatment of hypertension in adults, recommends initiating antihypertensive treatment in individuals with a confirmed diagnosis of hypertension (systolic BP [SBP] of ≥140mmHg or diastolic BP [DBP] of ≥90mmHg). The South African hypertension guideline also recommends initiating treatment in patients with BP levels in this range.1,2 Antihypertensive treatment is recommended in individuals with existing CVD, as well as
those without CVD, but with an elevated risk of CVD, diabetes, or chronic kidney disease, and a SBP level of 130-139mmHg.1 Initiation of treatment should start no later than four weeks following diagnosis of hypertension. If BP level is high (eg SBP ≥160mmHg or DBP ≥100mmHg) or there is accompanying evidence of end organ damage, initiation of treatment should be started without delay.1
Long-acting antihypertensives are preferred. Examples of indications to consider specific agents include diuretics or CCBs in patients over 65 years or those of African descent, beta-blockers in ischaemic heart disease, ACEis/ARBs in patients with severe proteinuria, diabetes, heart failure or kidney disease.1
Recommended pharmacological treatment
The WHO recommends combination therapy, preferably with a single-pill combination as initial treatment. Initial first-line therapy recommended by the South African hypertension guideline includes: a diuretic (thiazide-like or thiazide), ACEi or ARB, and/or CCB used as mono- or combination therapy.1,4 Combination therapy should be considered if clinically appropriate ab initio if BP is ≥160/100mmHg as this is associated with better clinical outcomes and earlier
For adults with hypertension, the WHO recommends the use of drugs from any of the following three classes as initial treatment:1 Thiazide and thiazide-like agents
1
2 3
Angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) Long-acting dihydropyridine calcium channel blockers (CCBs).
Fixed-dose combination preferred as initial treatment
achievement of target BP.4
