In Hypertension, ACE Inhibitor Plus Calcium Channel Blocker Is Superior to ACE Inhibitor Plus Diuretic

Pairing an ACE inhibitor with a calcium channel blocker, rather than a diuretic, may offer greater cardiovascular benefit to hypertensive patients, reports the New England Journal of Medicine.

In the industry-funded ACCOMPLISH trial, some 11,500 hypertensive adults at high risk for cardiovascular events were randomized to receive the ACE inhibitor benazepril plus either the calcium channel blocker amlodipine or the diuretic hydrochlorothiazide.

The trial was stopped early, after 3 years' follow-up, because of superior outcomes with benazepril-amlodipine. Namely, the incidence of the primary endpoint — a composite of cardiovascular events and cardiovascular death — was 9.6% with benazepril-amlodipine and 11.8% with benazepril-hydrochlorothiazide. (Blood pressure reductions were similar in the two groups.)

An editorialist says "it is time to reexamine" the "strong preference" for thiazide diuretics as initial therapy for hypertension. He calls for "greater flexibility" in drug choice, noting that it should be driven by "compelling indications or contraindications, coexisting conditions, adverse effects, race, and the clinician's experience."