Effects of combination therapy on the heart

The presence of left ventricular hypertrophy (LVH) usually indicates that hypertension is moderately severe and that combination therapy will be required to control blood pressure (BP). Unfortunately, most studies on the reduction of LVH have been done with monotherapy. Our knowledge of combination therapy in the treatment of hypertensive heart disease is to a great extent extrapolation from monotherapy. Angiotensin-converting enzyme (ACE) inhibitors in combination with calcium antagonists ought to be particularly efficacious in reducing LVH. Drug classes that either stimulate the renin angiotensin system or the sympathetic nervous system are less likely to reduce LVH and should be avoided. In hypertensive patients with congestive heart failure, amlodipine should be added to triple therapy with an ACE inhibitor, whereas in the post myocardial ischemia patient, verapamil may exert some additional beneficial effects with regard to reinfarction rates. Of note, given that two drugs when used separately are beneficial in a disorder does not necessarily mean that their combination is equally or even more beneficial. Thus, combination therapy should primarily be used for lowering arterial pressure and only secondarily to possibly improve concomitant pathophysiologic conditions associated with hypertensive heart disease.