Abstract
Background
Efficacy of blood pressure (BP) lowering may differ between clinical trials and what
is observed in clinical practice. These differences may contribute to poor BP control
rates among those at risk.
Objective
We conducted an observational study to determine the BP-lowering efficacy of angiotensin
receptor blocker (ARB) versus non–ARB-based antihypertensive treatments in a large
Canadian primary care database.
Methods
We analyzed the South Western Ontario database of 170,000 adults (aged >18 years)
with hypertension persisting with antihypertensive medication for ≥9 months. Routine
standard of care office BP was measured using approved manual aneroid or automated
devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence
(presence of initial antihypertensive prescription at the first, second, third, and
fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular
(CV) event (ie, myocardial infarction) were studied.
Results
After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target
BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) (P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) (P > 0.05), 21% (221 of 1050) on β-blockers (P = 0.002), and 19% (276 of 1450) on diuretics (P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of
873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared
with non–ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan
+ HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients
receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261),
valsartan (194 of 462), and candesartan (168 of 401) (P = 0.001 for each). After 4 years, persistence rates were not statistically different
among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs
and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly
different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ
(96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving
ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%–5.0%
for other ARBs; P < 0.02).
Conclusions
In this real-world setting, hypertensive adults treated with ARBs versus β-blockers
or diuretics were more likely to have evidence-based target BP recorded. In addition,
patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Clinical TherapeuticsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.Lancet. 2002; 360: 1903-1913
- Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.Circulation. 2007; 115: e69-e171
- 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension.J Hypertens. 2003; 21: 1983-1992
- The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2—therapy.Can J Cardiol. 2009; 25: 287-298
- Awareness and misconception of hypertension in Canada: results of a national survey.Can J Cardiol. 2005; 21: 589-593
- The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.JAMA. 2002; 288: 2981-2997
- Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.Lancet. 2002; 359: 995-1003
- Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial.Lancet. 2005; 366: 895-906
- Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial.Lancet. 2002; 360: 752-760
- Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial.Lancet. 1998; 351: 1755-1762
- Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial.Lancet. 2004; 363: 2022-2031
- Effects of losartan on cardiovascular morbidity and mortality in patients with isolated systolic hypertension and left ventricular hypertrophy: a Losartan Intervention for Endpoint Reduction (LIFE) substudy.JAMA. 2002; 288: 1491-1498
- Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.BMJ. 2003; 326: 1427
- Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.N Engl J Med. 2001; 345: 851-860
- The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial.J Hypertens. 2003; 21: 875-886
- VALIANT (VALsartan In Acute myocardial iNfarcTion) trial.Expert Opin Pharmacother. 2005; 6: 507-512
- Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme.Lancet. 2003; 362: 759-766
- Role of blood pressure and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).Lancet. 2005; 366: 907-913
- Telmisartan, ramipril, or both in patients at high risk for vascular events.N Engl J Med. 2008; 358: 1547-1559
- The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.JAMA. 2003; 289: 2560-2572
- 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).J Hypertens. 2007; 25: 1105-1187
- Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document.J Hypertens. 2009; 27: 2121-2158
- Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention.Circulation. 2007; 115: 2761-2788
- Is health care ready for Six Sigma quality?.Milbank Q. 1998; 76 (510): 565-591
- Role of outcome trials in providing information on antihypertensive treatment: importance and limitations.Am J Hypertens. 2006; 19: 1-7
- Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.BMJ. 1999; 318: 527-530
- Evidence-based medicine in hypertension: what type of evidence?.J Hypertens. 2005; 23: 1113-1120
- A comparison between persistence to therapy in ALLHAT and in everyday clinical practice: a generalizability issue.Can J Cardiol. 2004; 20: 417-421
- Developing and evaluating complex interventions: the new Medical Research Council guidance.BMJ. 2008; 337: a1655
- Randomized clinical trials and observational studies: guidelines for assessing respective strengths and limitations.JACC Cardiovasc Interv. 2008; 1: 211-217
- Importance of observational studies in clinical practice.Clin Ther. 2007; 29: 1284-1292
- Hypertension and outcomes research.Am J Hypertens. 1996; 9: 178-183
- The effect of irbesartan in reducing cardiovascular risk in hypertensive type 2 diabetic patients: an observational study in 16,600 patients in primary care.Curr Med Res Opin. 2004; 20: 1625-1631
- Metabolic effects of an AT1-receptor blockade combined with HCTZ in cardiac risk patients: a non interventional study in primary care.BMC Cardiovasc Disord. 2008; 8: 30
- Irbesartan for the treatment of hypertension in patients with the metabolic syndrome: a sub analysis of the Treat to Target post authorization survey.Cardiovasc Diabetol. 2007; 6: 12
- Losartan: a study of pharmacovigilance data on 14,522 patients.J Hum Hypertens. 1999; 13: 551-557
- The KARTAN study: a postmarketing assessment of irbesartan in patients with hypertension.Clin Ther. 2004; 26: 232-244
- Effectiveness of eprosartan in diabetic hypertensive patients.Eur J Intern Med. 2008; 19: 27-31
- Effect of three months' treatment with irbesartan on blood and pulse pressure of hypertensive type 2 diabetic patients: open, observational study in 31,793 patients.Curr Med Res Opin. 2005; 21: 1433-1440
Sharplin P, Beckham C, Televantou F, Chamberlain G. Early vs. late usage of angiotensin receptor blockers in the antihypertensive treatment pathway. Presented at American Society of Hypertension; May 14-17, 2008; New Orleans, LA.
Sharplin P, Beckham C, Televantou F, Chamberlain G. An analysis of the antihypertensive effectiveness of ARBs vs. ACE inhibitors. Presented at International Society for Pharmacoeconomics and Outcomes Research; November 8-11, 2008; Athens, Greece.
Sharplin P, Chamberlain G, Beckham C, Wisniacki N. Antihypertensive effect of angiotensin receptor blockers vs. other classes of antihypertensives in UK primary care. Presented at American College of Cardiology; March 29-April 1, 2008; Chicago, IL.
Petrella RJ, Koa H. How does the dual combination of ARBsdHCTZ compare to other dual combinations in the treatment of hypertension? Presented at ISPOR 12th Annual European Congress; October 24-27, 2009; Paris, France. Poster PCV17.
Petrella RJ, Koa H. What is the impact of ARBs versus other anti-hypertensives on CV events in hypertensive patients? Presented at ISPOR 12th Annual European Congress; October 24-27, 2009; Paris, France. Poster PCV12.
Petrella RJ, Massien C. What is the effectiveness of ARBs versus other anti-hypertensives when used as monotherapy in the real-world? Presented at ISPOR 12th Annual European Congress; October 24-27, 2009; Paris, France. Poster PCV23.
Petrella RJ, Charki M. An analysis of the anti-hypertensive effectiveness of combination therapies containing ARBs versus ACE inhibitors. Presented at ISPOR 12th Annual European Congress; October 24-27, 2009; Paris, France. Poster PCV21.
- 2008 Clinical practice guidelines for the prevention and management of diabetes in Canada.Can J Diabetes. 2008; 32: S1-S201
- Targeting effective blood pressure control with angiotensin receptor blockers.Int J Clin Pract. 2006; 60: 315-320
- The value of irbesartan in the management of hypertension.Expert Opin Pharmacother. 2009; 10: 1817-1831
- Angiotensin II antagonists in the treatment of hypertension: more similarities than differences.J Clin Hypertens (Greenwich). 2000; 2: 253-257
- Comparative efficacy of two angiotensin II receptor antagonists, irbesartan and losartan in mild-to-moderate hypertension.Am J Hypertens. 1998; 11: 445-453
- Valsartan vs. other angiotensin II receptor blockers in the treatment of hypertension: a meta-analytical approach.Int J Clin Pract. 2009; 63: 766-775
- Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States.Arch Intern Med. 2007; 167: 141-147
- Hypertension treatment and control in five European countries, Canada, and the United States.Hypertension. 2004; 43: 10-17
- Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy.N Engl J Med. 2001; 345: 861-869
- A home blood pressure monitoring study comparing the antihypertensive efficacy of two angiotensin II receptor antagonist fixed combinations.Am J Hypertens. 2005; 18: 1482-1488
- Ambulatory blood pressure comparison of the anti-hypertensive efficacy of fixed combinations of irbesartan/hydrochlorothiazide and losartan/hydrochlorothiazide in patients with mild-to-moderate hypertension.J Int Med Res. 2005; 33: 620-631
- The effect of discontinuation of antihypertensives on the risk of acute myocardial infarction and stroke.Curr Med Res Opin. 2008; 24: 121-127
- Clinical practice and recent recommendations in hypertension management—reporting a gap in a global survey of 1259 primary care physicians in 17 countries.Curr Med Res Opin. 2007; 23: 783-791
- Patterns of persistence with antihypertensive medications in newly diagnosed hypertensive patients in Italy: a retrospective cohort study in primary care.J Hypertens. 2005; 23: 2093-2100
- A population-based European cohort study of persistence in newly diagnosed hypertensive patients.J Hum Hypertens. 2002; 16: 569-575
- The interaction of patient perception of overmedication with drug compliance and side effects.J Gen Intern Med. 1998; 13: 182-185
- A retrospective study of persistence with single-pill combination therapy vs. concurrent two-pill therapy in patients with hypertension.Manag Care. 2000; 9: 2-6
- Patterns of compliance with once versus twice daily antihypertensive drug therapy in primary care: a randomized clinical trial using electronic monitoring.Can J Cardiol. 1997; 13: 914-920
- The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly.Arch Intern Med. 1990; 150: 841-845
- Improving patient compliance: a major goal in the management of hypertension.J Clin Hypertens (Greenwich). 2003; 5: 127-132
- Efficacy and safety of irbesartan/HCTZ combination therapy as initial treatment for rapid control of severe hypertension.J Clin Hypertens (Greenwich). 2006; 8: 850-857
- Continuation of initial antihypertensive medication after 1 year of therapy.Clin Ther. 1998; 20: 671-681
- Determinants of persistence in hypertensive patients treated with irbesartan: results of a postmarketing survey.BMC Cardiovasc Disord. 2005; 5: 13
- Long-term persistence with antihypertensive drugs in new patients.J Hum Hypertens. 2002; 16: 439-444
- Persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies.J Am Board Fam Med. 2007; 20: 72-80
- Differences in antihypertensive drug persistence associated with drug class and gender: a PHARMO study.Pharmacoepidemiol Drug Saf. 2005; 14: 795-803
- Persistence with antihypertensive treatments: results of a 3-year follow-up cohort study.Eur J Clin Pharmacol. 2007; 63: 1055-1061
- Choices, persistence and adherence to antihypertensive agents: evidence from RAMQ data.Can J Cardiol. 2008; 24: 269-273
- Antihypertensive persistence and drug class.Can J Cardiol. 2002; 18: 649-656
- Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial.Lancet. 2007; 370: 829-840
- Patient adherence with amlodipine, lisinopril, or valsartan therapy in a usual-care setting.J Manag Care Pharm. 2003; 9: 424-429
- Discontinuation and persistence of antihypertensive drugs among newly diagnosed hypertensive patients in French general practice (abstract).J Hypertens. 2009; 27: 1386
- Discontinuation of antihypertensive drugs among newly diagnosed hypertensive patients in UK general practice.J Hypertens. 2006; 24: 1193-1200
- The safety of valsartan: results of a postmarketing surveillance study on 12881 patients in England.J Hum Hypertens. 2002; 16: 795-803
- Angiotensin II type 1 receptor blockers.Circulation. 2001; 103: 904-912
- Safety and tolerability of losartan potassium, an angiotensin II receptor antagonist, compared with hydrochlorothiazide, atenolol, felodipine ER, and angiotensin-converting enzyme inhibitors for the treatment of systemic hypertension.Am J Cardiol. 1995; 75: 793-795
- Reversal of atrial electrical remodeling after cardioversion of persistent atrial fibrillation in humans.Circulation. 2000; 101: 1145-1151
- Safety of irbesartan in the treatment of mild to moderate systemic hypertension.Am J Cardiol. 1998; 82: 179-182
- A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure.N Engl J Med. 2001; 345: 1667-1675
- The effect of valsartan, captopril, or both on atherosclerotic events after acute myocardial infarction: an analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT).J Am Coll Cardiol. 2006; 47: 726-733
- Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial.Lancet. 2003; 362: 767-771
- Clinical trials update from the European Society of Cardiology Meeting 2009: AAA, RELY, PROTECT, ACTIVE-I, European CRT survey, German pre-SCD II registry, and MADIT-CRT.Eur J Heart Fail. 2009; 11: 1214-1219
- Irbesartan in patients with heart failure and preserved ejection fraction.N Engl J Med. 2008; 359: 2456-2467
- Department of Veterans Affairs single-drug therapy of hypertension study.Am J Hypertens. 1995; 8: 189-192
Article info
Publication history
Published online: September 02, 2011
Accepted:
August 10,
2011
Identification
Copyright
© 2011 Elsevier HS Journals, Inc. Published by Elsevier Inc. All rights reserved.
