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Published on: May 26, 2022
Angiotensin II receptor blocker-based therapy in Japanese elderly, high-risk, hypertensive patients
Hisao Ogawa1, Shokei Kim-Mitsuyama, Kunihiko Matsui
1Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
Insights
For elderly patients with high cardiovascular risk, combining an angiotensin II receptor blocker with a calcium channel blocker significantly lowered blood pressure and reduced cardiovascular events compared to high-dose monotherapy.
Area of Science:
- Cardiology
- Pharmacology
- Geriatrics
Background:
- Elderly hypertensive patients with high cardiovascular risk require optimal treatment strategies.
- The comparative efficacy of high-dose angiotensin II receptor blocker (ARB) therapy versus ARB plus calcium channel blocker (CCB) combination therapy remains unclear in this population.
Purpose of the Study:
- To compare the efficacy of high-dose ARB therapy with ARB + CCB combination therapy in elderly, high-risk Japanese hypertensive patients.
Main Methods:
- The OSCAR study randomized 1164 hypertensive patients (aged 65-84) with type 2 diabetes or cardiovascular disease.
- Patients received either high-dose olmesartan (40 mg/d) or olmesartan (20 mg/d) plus a CCB.
- The primary endpoint was a composite of cardiovascular events and non-cardiovascular death over 3 years.
Main Results:
- The ARB + CCB group achieved significantly lower blood pressure (132.6/72.6 mm Hg) than the high-dose ARB group (135.0/74.3 mm Hg) at 36 months.
- While the overall primary endpoint event rate was not significantly different (P=.17), the ARB + CCB combination showed a trend towards fewer events.
- A significant treatment-by-subgroup interaction (P=.02) was observed: the ARB + CCB combination was beneficial in patients with baseline cardiovascular disease but not in those without.
Conclusions:
- Combination therapy with an angiotensin II receptor blocker and a calcium channel blocker is more effective in lowering blood pressure than high-dose monotherapy in elderly hypertensive patients.
- This combination therapy reduced cardiovascular events in patients with pre-existing cardiovascular disease.
- Adding a second antihypertensive agent offers superior blood pressure control compared to increasing the dose of a single agent.
Background:
It is unknown whether high-dose angiotensin II receptor blocker therapy or angiotensin II receptor blocker + calcium channel blocker combination therapy is better in elderly hypertensive patients with high cardiovascular risk. The objective of the study was to compare the efficacy of these treatments in elderly, high-risk Japanese hypertensive patients.
Methods:
The OlmeSartan and Calcium Antagonists Randomized (OSCAR) study was a multicenter, prospective, randomized, open-label, blinded-end point study of 1164 hypertensive patients aged 65 to 84 years with type 2 diabetes or cardiovascular disease. Patients with uncontrolled hypertension during treatment with olmesartan 20 mg/d were randomly assigned to receive 40 mg/d olmesartan (high-dose angiotensin II receptor blocker) or a calcium channel blocker + 20 mg/d olmesartan (angiotensin II receptor blocker + calcium channel blocker). The primary end point was a composite of cardiovascular events and noncardiovascular death.
Results:
During a 3-year follow-up, blood pressure was significantly lower in the angiotensin II receptor blocker + calcium channel blocker group than in the high-dose angiotensin II receptor blocker group. Mean blood pressure at 36 months was 135.0/74.3 mm Hg in the high-dose angiotensin II receptor blocker group and 132.6/72.6 mm Hg in the angiotensin II receptor blocker + calcium channel blocker group. More primary end points occurred in the high-dose angiotensin II receptor blocker group than in the angiotensin II receptor blocker + calcium channel blocker group (58 vs 48 events, hazard ratio [HR], 1.31, 95% confidence interval, 0.89-1.92; P=.17). In patients with cardiovascular disease at baseline, more primary events occurred in the high-dose angiotensin II receptor blocker group (HR, 1.63, P=.03); in contrast, fewer events were observed in the subgroup without cardiovascular disease (HR, 0.52, P=.14). This treatment-by-subgroup interaction was significant (P=.02).
Conclusion:
The angiotensin II receptor blocker and calcium channel blocker combination lowered blood pressure more than the high-dose angiotensin II receptor blocker and reduced the incidence of primary end points more than the high-dose angiotensin II receptor blocker in patients with cardiovascular disease. The addition of a second antihypertensive agent is more effective at lowering blood pressure than simply doubling the dose of an existing agent.
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