Monotherapy Blood Pressure Response and Control Rates in Treatment-Naïve Patients with Arterial Hypertension: A Randomized Comparison of Four Different Antihypertensive Drug Classes.

Thilo Burkard, Manuel Haschke, Michael Mayr, Annina Salome Vischer, Maria Bertsch, Vera Van der Velpen, Franziska Küng, Thenral Socrates

Journal: Kidney & blood pressure research 2025;50(1):325-340

PMID: 40258344

Free Full Text on S. Karger AG, Basel, Switzerland View on PubMed

Abstract

INTRODUCTION

Four different antihypertensive drug classes are equivalently recommended in the previous guidelines for first-line treatment of arterial hypertension (HTN). However, it is unclear, whether one of these drugs is more capable than the others to reach blood pressure (BP) control. We sought to compare response rates and BP control in these 4 classes.

METHODS

Patients with newly diagnosed mild to moderate HTN on 24-h BP measurements (ABPM) were randomized in a 1:1:1:1 fashion to either perindopril, olmesartan, amlodipine, or hydrochlorothiazide (HCT). ABPM was completed at baseline (BL) and after 4 weeks of half dose (treatment period 1 [TP1]). If BP control was not reached after TP1, drug dose was doubled and another ABPM completed after 4 weeks (treatment period 2 [TP2]). Patients were classified as controlled if 24-h mean BP was <130/80 mm Hg, awake BP <135/85 mm Hg, and night BP <120/70 mm Hg, and as optimal if 24-h mean BP was 115-124/65-74 mm Hg.

RESULTS

88 patients were randomized: 20 (23%) to perindopril, 23 (26%) to olmesartan, 24 (27%) to amlodipine, and 21 (24%) to HCT. Median 24-h mean BP reduction from BL to TP1 was -11/-6 mm Hg and from TP1 to TP2 -4/-2 mm Hg. The highest BP reduction was reached with olmesartan (-15/-10 mm Hg), particularly for diastolic values, the lowest with HCT (-8/-1 mm Hg). 27% of patients reached systo-diastolic BP control, with the best control rate with perindopril and olmesartan (40 and 39%), the lowest with HCT (5%), and 21%/18% reached an optimal treatment goal for systolic/diastolic 24-h mean values, respectively, after TP1. Three additional participants (4%) reached BP control after TP2.

CONCLUSION

Initial antihypertensive monotherapy failed in most patients (73% uncontrolled, 21%/18% reached optimal treatment goal at TP1) even in low-risk patients, with efficacy varying by drug class (inhibitors of the renin-angiotensin-aldosterone system best, HCT least). These findings support guideline-recommended combination therapy.

Address: Medical Outpatient Department and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel, Basel, Switzerland.; Faculty of Medicine, University of Basel, Basel, Switzerland.; Medical Outpatient Department and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel, Basel, Switzerland.; Medical University Clinic, Kantonsspital Baselland/Bruderholz, Bruderholz, Switzerland.; Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.; Faculty of Medicine, University of Basel, Basel, Switzerland.; Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.; Medical Outpatient Department and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel, Basel, Switzerland.; Faculty of Medicine, University of Basel, Basel, Switzerland.; Department of Cardiology, University Hospital Basel, Basel, Switzerland.

DOI: 10.1159/000545908

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MeSH Terms: Humans, Antihypertensive Agents, Hypertension, Middle Aged, Male, Female, Blood Pressure, Aged, Perindopril, Amlodipine, Hydrochlorothiazide, Imidazoles, Adult, Tetrazoles, Treatment Outcome