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Cardiac effects of combination therapy
1Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana 70121, USA.
Insights
Combination therapy for hypertension, particularly with ACE inhibitors and calcium antagonists, shows promise for reducing left ventricular hypertrophy. However, combinations should primarily target blood pressure reduction.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Hypertension management often requires multiple drugs, yet research predominantly focuses on monotherapy.
- Current understanding of combination therapy for hypertension largely relies on extrapolations from monotherapy studies.
Purpose of the Study:
- To evaluate the efficacy of drug combinations in managing hypertension and associated conditions.
- To identify optimal drug classes for combination therapy, particularly for reducing left ventricular hypertrophy (LVH).
Main Methods:
- Review and synthesis of existing literature on antihypertensive drug combinations.
- Analysis of the potential benefits and drawbacks of specific drug classes in combination therapy.
Main Results:
- Angiotensin converting enzyme (ACE) inhibitors combined with calcium antagonists are suggested to be effective in reducing LVH.
- Drug classes stimulating the renin-angiotensin or sympathetic nervous systems may be less effective for LVH reduction.
- Specific recommendations for amlodipine in heart failure and verapamil in post-myocardial ischemia are discussed.
Conclusions:
- Combination therapy for hypertension should prioritize arterial pressure reduction.
- Secondary benefits, such as improving pathophysiologic conditions like LVH, should be considered cautiously.
- The efficacy of combined drugs does not automatically equate to enhanced benefits over monotherapy.
Abstract:
Control of hypertension and treatment of concomitant pathophysiologic conditions require use of multiple drugs. Unfortunately, most studies regarding hypertensive disease have focused on monotherapy. Thus, our knowledge of combination therapy in the treatment of hypertension is, to a great extent, extrapolation from monotherapy. Angiotensin converting enzyme (ACE) inhibitors in combination with calcium antagonists should be particularly efficacious in reducing left ventricular hypertrophy (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 postmyocardial ischemia patient, verapamil may exert some additional beneficial effects with regard to reinfarction rates. 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.