What is a recommended dual therapy regimen for hypertension?

Recommended Dual Therapy for Hypertension

For most patients with hypertension, the recommended dual therapy regimen is a combination of a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker (CCB) or a thiazide/thiazide-like diuretic, preferably as a single-pill combination. 1

First-Line Dual Therapy Options

Preferred Combinations:

• Option 1: ACE inhibitor + dihydropyridine CCB (e.g., lisinopril + amlodipine)
• Option 2: ARB + dihydropyridine CCB (e.g., valsartan + amlodipine)
• Option 3: ACE inhibitor + thiazide/thiazide-like diuretic (e.g., lisinopril + hydrochlorothiazide)
• Option 4: ARB + thiazide/thiazide-like diuretic (e.g., valsartan + hydrochlorothiazide)

Special Population Considerations:

• Black patients: Preferred initial combination is ARB + dihydropyridine CCB or thiazide/thiazide-like diuretic 1
• Non-Black patients: Any of the above combinations are appropriate 1

Implementation Strategy

1. Initial Approach: Start with low-dose combination therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) 1

2. Formulation: Use single-pill combinations whenever possible to improve adherence 1

3. Dose Titration: If BP remains uncontrolled, increase to full doses of the combination before adding a third agent 1

4. Monitoring: Follow up monthly after initiation until target BP is reached 1

Evidence Supporting Dual Therapy

The 2024 European Society of Cardiology guidelines strongly recommend combination therapy for most patients with hypertension, citing better BP control and improved adherence 1. This is supported by the 2022 WHO guidelines which recommend combination therapy preferably with a single-pill combination as initial treatment 1.

Clinical studies demonstrate the efficacy of these combinations:

• Amlodipine + valsartan combination showed significant BP reductions comparable to lisinopril + hydrochlorothiazide in patients with stage 2 hypertension 2
• Amlodipine + benazepril combination achieved higher BP control rates compared to amlodipine monotherapy in severe hypertension 3

Target Blood Pressure Goals

• General target: <130/80 mmHg for most adults 1, 4
• Older adults (≥65 years): Target systolic BP <130 mmHg if tolerated 1
• Patients with known cardiovascular disease: Target systolic BP <130 mmHg 1

Important Considerations and Cautions

• Avoid combining two RAS blockers (ACE inhibitor + ARB) as this increases adverse effects without additional benefit 1

• Triple therapy: If BP remains uncontrolled on dual therapy, progress to triple therapy with RAS blocker + CCB + thiazide/thiazide-like diuretic 1

• Resistant hypertension: If BP remains uncontrolled on triple therapy, consider adding spironolactone as a fourth agent 1

• Adherence: Single-pill combinations significantly improve medication adherence compared to separate pills 1, 4

• Monitoring: Regular follow-up is essential - monthly until BP control is achieved, then every 3-6 months 1, 4

Dual therapy with complementary mechanisms of action provides synergistic effects for BP control, with evidence showing that combinations like amlodipine/valsartan/HCTZ can provide superior BP control compared to dual therapies alone for patients requiring more intensive treatment 5.