THE Journal of CliniCal HypErTEnsion suppl 1. Vol. 10 no. 1 January 20082

This supplement to The Journal of Clinical Hypertension provides practitioners with an

update on the latest approaches to defining and treating a commonly recognized but still impor-tant clinical challenge. Despite decades of educa-tional efforts by organizations such as the Joint national Committee on prevention, Detection, Evaluation, and Treatment of High Blood pressure; the European society of Cardiology; and the European society of Hypertension, elevated blood pressure (Bp) remains a leading cause of morbidity and mortality, and while hypertension treatment and control rates have increased to a great degree, there is still room for improvement. The articles in the supplement are intended to address a number of issues.

“risk-Based Classification of Hypertension and the role of Combination Therapy” by Matthew r. Weir, MD, describes the evolution of the defini-tion of hypertension to take into account not only classifications based on Bp thresholds but also the patient’s global risk of cardiovascular disease. The potential of combination therapy, an approach that has been advocated for many years with the use of diuretics, b-blockers, angiotensin-converting

enzyme (aCE) inhibitors, calcium channel blockers (CCBs), and more recently angiotensin ii receptor blockers (arBs) in various combinations, is dis-cussed. a regimen that includes an inhibitor of the renin-angiotensin-aldosterone system to achieve more stringent Bp control, interrupt vascular dis-ease mechanisms, and ultimately decrease the risk of cardiovascular events is explored.

Jan Basile, MD, reviews the “importance of prompt Blood pressure Control” in high-risk patients, as supported by data from several clini-cal trials, such as the Valsartan antihypertensive long-Term use Evaluation (ValuE), the systolic Hypertension in Europe (sysT-Eur), and the study on Cognition and prognosis in the Elderly (sCopE) trials, and in particular examines evi-dence that combination therapy might facilitate the attainment of prompt Bp control in these patients.

William J. Elliott, MD, phD, proposes a num-ber of answers to the question, “What factors Contribute to the inadequate Control of Elevated Blood pressure?” He emphasizes the need to overcome “therapeutic inertia” as well as patient nonadherence to achieve Bp goals and the poten-tial role of single-pill combination products in enhancing patient persistence and compliance with antihypertensive therapy.

next, George l. Bakris, MD, discusses “Combined Therapy With a Calcium Channel Blocker and an angiotensin ii Type 1 receptor Blocker.” The usefulness of combination therapy with a CCB and an arB is supported by experi-mental data showing that each of these classes of antihypertensive agents favorably affect under-lying mechanisms of disease. The first agent to www.lejacq.com ID: 8026

I n t r o d u c t i o n

Shifting Paradigms in Defining and Treating Hypertension: Addressing Global Risk With Combination Therapy

Jan Basile, MD Guest Editor

From the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SCAddress for correspondence:Jan Basile, MD, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401E-mail: jan.basile@med.va.gov

The Journal of Clinical Hypertension® (ISSN 1524-6175) is published monthly by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright ©2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.

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suppl 1. Vol. 10 no. 1 January 2008 THE Journal of CliniCal HypErTEnsion 3

provide this combination in a fixed-dose formu-lation consisted of amlodipine plus valsartan. another agent, combining amlodipine with olm-esartan, has recently been approved. This article summarizes data from some of the clinical trials establishing the Bp-lowering efficacy and toler-ability of these combinations.

an increasingly important issue in hyperten-sion management is “Hypertension Control in the Elderly.” Joel M. neutel, MD, and lawrence i. Gilderman, Do, state that most elderly hyper-tensive patients will require combination therapy to reach target levels of systolic Bp. in addition, initial fixed-dose combination therapy may achieve more rapid Bp control and improve adherence. Clinical trials in older patients have shown greater Bp reductions with a renin-angiotensin-aldosterone system blocker plus a CCB than with monothera-py; these combination regimens are well tolerated. it remains to be seen whether this combination proves to be as effective or more effective than other medications in reducing morbidity and mor-tality rates in this population.

Kenneth a. Jamerson, MD, and Jan Basile, MD, address the issue of “prompt, aggressive Blood pressure lowering in High-risk patients.” Combination therapy using fixed-dose combinations

or free combinations of 2 or 3 antihypertensive drugs is usually necessary to achieve Bp goals in difficult-to-treat (stage 2 hypertension and african american) and high-risk (diabetes mellitus) patients. Complementary mechanisms of action and enhanced efficacy and tol-erability provide the rationale for use of combination therapy that includes an arB and a CCB as well as combinations of a diuretic/aCE inhibitor, an aCE inhibitor/CCB, or a diuretic/b-blocker. recently pub-lished studies have demonstrated the effectiveness of combinations of a CCB and an arB in promptly low-ering Bp in african american patients and patients with stage 2 and severe hypertension.

The authors trust that these articles will not only prove interesting to read but that the informa-tion contained in this supplement will contribute to improved patient outcomes.

Disclosure: Dr Basile receives grant/research support from the National Heart, Lung, and Blood Institute, Boehringer Ingelheim (ONTARGET), and Novartis. He has served as a consultant for AstraZeneca, Merck, Novartis, and Daiichi Sankyo and has served on the Speakers’ Bureau of Abbott, AstraZeneca, Boehringer Ingelheim, Forest, Merck, Novartis, Pfizer, and Daiichi Sankyo. The author acknowledges the assistance of Landmark Programs, Inc. in preparing this article and styling the paper for journal submission. Editorial support was funded by Novartis Pharmaceuticals Corporation and the author received an honorarium for time and effort spent prepar-ing this article.

The Journal of Clinical Hypertension® (ISSN 1524-6175) is published monthly by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright ©2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.

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