NEW YORK (Reuters Health) – In hypertensive patients, including Blacks, combining amlodipine, rather than hydrochlorothiazide, with benazepril effectively reduced multiple cardiovascular outcomes, including death, in a post-hoc analysis of the ACCOMPLISH trial.

In the randomized double-blind trial involving 11,506 hypertensive patients, this combination reduced the primary composite cardiovascular end point by 20%, but most of the patients were not Black.

“Serious health disparities persist such that hypertension control rates continue to be worse among Black Americans,” Dr. Robert Brook of Wayne State University in Detroit told Reuters Health by email. “It is also now well-known that to achieve current blood pressure goals of <130/80 mm Hg, most patients, regardless of race, require two or more medications.”

“We showed in the ACCOMPLISH trial that just like with other groups of people, Black patients had similar blood pressure control and tended to have fewer cardiovascular events when a calcium channel blocker rather than a thiazide diuretic was combined with an angiotensin-converting enzyme inhibitor,” he said.

“Our analyses must be considered exploratory, and because Black patients represented a minority of the study population the results did not quite reach statistical significance,” he noted. “Nevertheless, our findings are encouraging and strongly support efforts for Black patients and their healthcare providers to prioritize treating hypertension aggressively, as they can achieve similar blood pressure control and cardiovascular benefits as White patients if two or more medications are used.”

“Our findings also support the need for future trials to clarify the optimal combination antihypertensive regimen in patients of all races,” he said.

As reported in Hypertension, the team’s post hoc analysis evaluated whether the primary composite and individual end points (death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac death, and coronary revascularization) were reduced in Black participants (1,371; 12%) as well as all others (10,083; 88%).

Mean baseline characteristics in Black participants were similar in the amlodipine/benazepril and hydrochlorothiazide/benazepril groups: age, 67; BMI, about 33; blood pressure medications, 2.4; and prerandomization blood pressure levels, study labs (e.g., glucose and creatinine), and cardiometabolic conditions. Average in-trial blood pressure levels, from three to 42 months, were also similar at about 133 mmHg.

The primary composite outcome occurred less frequently in the amlodipine/benazepril limb (HR, 0.70), as did most individual component end points. No interaction terms for effect modification by Black race on the HRs of treatment with amlodipine/benazepril were significant.

The authors state, “While the primary outcome (was) not statistically different between limbs, at the very least, our analyses found no evidence that race modified the superior benefits of amlodipine/benazepril…or that a diuretic-based regimen conveyed special benefits in Black participants.”

Dr. Joseph Ravenell, associate professor in the departments of Population Health and Medicine at NYU Langone Health in New York City, commented in an email to Reuters Health, “I agree with the findings of this new analysis. While inferences made from subgroup analyses have to be interpreted with caution, the fact that these findings in Black adults with high blood pressure align with findings of the original ACCOMPLISH study supports the authors’ conclusion that ACE inhibition and calcium channel blockade may be a preferred combination for Black and white hypertensive adults alike.”

“As noted by the authors,” he added, “future research should evaluate combinations known to be superior to the hydrochlorothiazide-based combination tested in the ACCOMPLISH trial.”

The ACCOMPLISH trial was funded by Novartis Pharmaceuticals.

SOURCE: https://bit.ly/3AdjBmh Hypertension, online August 23, 2021.

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