Beginning treatment of hypertension with one medicine versus | Figure 1

%27%3e%3cg%20id=%27Group-14%27%20transform=%27translate(13.000000,%20103.176124)%27%3e%3cg%20id=%27Group-Copy-5%27%20transform=%27translate(0.000000,%20182.676124)%27%3e%3crect%20id=%27Rectangle-8%27%20fill=%27%23E2E0DE%27%20x=%270%27%20y=%270%27%20width=%2736%27%20height=%2736%27%20rx=%2718%27%3e%3c/rect%3e%3cpath%20d=%27M28,27.6503435%20C28,22.127496%2023.5228474,17.6503435%2018,17.6503435%20C12.4771525,17.6503435%208,22.127496%208,27.6503435%20M18,16.3472505%20C20.8165136,16.3472505%2023.099749,14.0640151%2023.099749,11.2475015%20C23.099749,8.43098783%2020.8165136,6.1477524%2018,6.1477524%20C15.1834863,6.1477524%2012.9002509,8.43098783%2012.9002509,11.2475015%20C12.9002509,14.0640151%2015.1834863,16.3472505%2018,16.3472505%20Z%27%20id=%27Combined-Shape%27%20fill=%27%23FFFFFF%27%20fill-rule=%27nonzero%27%3e%3c/path%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/svg%3e)

Deleted account

Some actions are only available when you log in.

Report case

Report this to our moderators

Beginning treatment of hypertension with one medicine versus with a combination of two medicines

You can view up to 4 cases without signing up Sign up for unlimited access

Background

This is the first update of a review originally published in 2017. Hypertension (high blood pressure) is a long‐term condition that increases the risk of health problems such as heart attack, stroke, or kidney disease. Several types of medicines are used to treat hypertension. It is frequently the case that over time a person with hypertension will need more than one type of medicine to control their blood pressure. A doctor prescribing medicines to reduce the blood pressure for the first time in a patient has two options: using only one medicine (monotherapy) or using two medicines (combination therapy). Combination therapy can be in the same tablet or in different tablets. The potential advantage of using combination therapy is that blood pressure may fall faster, however it is unclear if this is better or worse in terms of avoiding health problems.

Study characteristics

We searched for clinical studies that compared starting treatment of hypertension in adults with monotherapy versus starting with combination therapy. Studies had to report results in terms of deaths, events due to diseases of the heart or the vessels (heart attack, stroke, or heart failure), deaths due to diseases of the heart or the vessels, or any health‐related serious side effects. We only selected studies with 50 or more people per group and that lasted at least 12 months. The evidence is current to April 2019.

Key results and certainty of the evidence

In this update we included one new study, for a total of four studies in the review involving 349 people treated with combination therapy and 419 treated with monotherapy. However, data were insufficient to answer our review question. There is a need for more and larger studies that compare monotherapy with combination therapy as the initial treatment of hypertension.

Read the full Cochrane Review here

Comment

Sign up to add a comment

More about this case

ResolvedVerified literature

Why you should join Figure 1

Sign up to explore now

Similar cases

\ \ Review question\ We determined how renin inhibitors (RIs) compared with angiotensin converting enzyme (ACE) inhibitors for treating hypertension.\ Background\ Hypertension is a worldwide public‐health challenge associated with high levels of occurrence and risks of circulatory and kidney disease. RIs were introduced into clinical use for hypertension in 2007. ACE inhibitors are widely prescribed for hypertension. However, the comparative effectiveness and safety of RIs and ACE inhibitors is not known.\ Search date\ We searched for evidence up to August 2020.\ Study characteristics\ We included randomized, active‐controlled, double‐blinded studies (RCTs) for this review. We include 11 RCTs involving 13,627 participants, with an average age from 51 to 74 years. Length of follow‐up ranged from four weeks to 36 months.\ Key results and certainty of evidence\ Low‐certainty evidence showed no difference between RIs and ACE inhibitors for deaths from any cause, for heart attacks, for serious side effects or for leaving the study because of side effects. Low‐certainty evidence suggested that RIs reduce blood pressure more than ACE inhibitors do, but this could have been due to bias in the design and conduct of the studies. More independent RCTs are needed to assess illnesses and deaths, and to see if the difference in blood pressure‐lowering is real.](https://app.figure1.com/case-detail/09a95744-7f8f-4f04-9a64-3e0285e48f57)

\ \ Aim\ This review aimed to find out if it is possible to stop blood pressure medications in older people. We also wanted to find out the effects of stopping these medications.\ We included adults aged 50 years and over who were taking blood pressure medications for high blood pressure (hypertension) or for prevention of heart diseases (primary prevention). We excluded studies with people who had previously had a heart attack, stroke or other heart disease (secondary prevention).\ We compared stopping or reducing the dose of blood pressure medications with continuing blood pressure medications.\ Background\ High blood pressure, also known as hypertension, is a risk factor for many diseases, such as heart attack, kidney failure and stroke. While hypertension usually produces no symptoms, keeping blood pressure under control is vital for preserving health and reducing the risk of serious conditions.\ Hypertension is often managed with lifestyle and blood pressure (antihypertensive) medications. There are many different types of blood pressure medications available.\ Antihypertensives can cause dangerous side effects, such as dizziness and fatigue which might lead to falls. Older people are at greater risk of medication side effects compared to younger people. It is unclear whether the benefits of antihypertensive medications outweigh the harms in older people.\ Study characteristics\ Our search to April 2019 found six studies, including 1,073 older adults in total. People in the studies had an average age of 58 to 82 years. In three of the studies, the dose of the antihypertensive was slowly lowered before stopping.\ Key results\ We found that stopping antihypertensive medications is possible in older adults. Most of the older people in the discontinuation groups did not need to restart their medication.\ We found low certainty of evidence that stopping antihypertensive medication increased blood pressure by a small amount.\ We found low or very low certainty of evidence that stopping blood pressure medications did not increase the risk of having a heart attack, stroke, hospitalisation or death.\ We found very low certainty of evidence that stopping blood pressure medications did not increase the risk of adverse events and may resolve side effects, but this was not reported well, and so we were unable to draw conclusions.\ None of the studies reported whether stopping blood pressure medications affected falls.\ Certainty of the evidence\ We rated the certainty of the evidence using four levels: very low, low, moderate, or high. High certainty evidence means that we are very confident in the results. Very low certainty evidence means that we are very uncertain about the results. We judged the certainty of evidence as very low and low.\ Conclusion\ It may be safe to stop antihypertensive medications in older people who are taking the medication for high blood pressure or primary prevention of heart disease.\ Older adults should not stop any of their medications without talking to a healthcare professional.\ Future studies should include older adults who are taking multiple other medications and/or living with frailty.](https://app.figure1.com/case-detail/5fa7c14b-b66d-4a8d-bb6d-5b8ca7ead842)

\ \ Key messages\ ‐ GLP‐1RA and SGLT2i (two new diabetes medicines) are likely to reduce the risk of death from cardiovascular disease and death from any cause in people with both diabetes and established cardiovascular disease (diseases of the heart and blood vessels).\ ‐ SGLT2i medicines are likely to reduce the risk of hospitalisation for heart failure and GLP‐1RA medicines may reduce fatal and non‐fatal stroke.\ ‐ We need further studies to find out if these medicines also have a positive effect on cardiovascular health in people without diabetes or if the effects seen in people with diabetes are due only to these medicines’ ability to control blood sugar.\ Cardiovascular disease is a general term for conditions that affect the heart and blood vessels. Fatty substances in the blood can build up and block blood vessels, leading to problems such as heart failure – when the heart cannot pump blood around the body properly – stroke and heart attacks.\ Some new types of diabetes medicines, DPP4i, GLP‐1RA and SGLT2i, have been designed to control blood sugar. They may also prevent cardiovascular complications in people with diabetes who also have cardiovascular disease.\ We wanted to know if DPP4i, GLP‐1RA and SGLT2i medicines are effective treatments for cardiovascular disease in people with established cardiovascular disease, both with and without diabetes. We also wanted to know whether these medicines cause unwanted effects.\ We found 31 studies. We were able to combine and analyse the evidence from 20 studies, with 129,465 participants. Six of the 20 studies investigated DPP4i, 7 studied GLP‐1RA and 7 investigated SGLT2i medicines, all compared with placebo. People in the studies were aged between 60 and 71 years and most people had diabetes.\ What are the limitations of the evidence?\ We are confident or moderately confident in the evidence for deaths from cardiovascular disease or any cause, heart attack, stroke and hospitalisation due to heart failure. We are less confident in the evidence for unwanted effects because few studies provided information on unwanted effects and they did not report many. Most studies included people with diabetes only so these results could be due to better control of their diabetes, rather than the medicines’ effect on cardiovascular disease.\ How up‐to‐date is this evidence?\ The evidence is current to 16 July 2020.](https://app.figure1.com/case-detail/9acaa674-a147-4f9c-9b11-b91c56b9f83d)

\ \ What are the benefits of using remote ischaemic conditioning (RIC; a noninvasive physical therapy that involves inflating blood pressure cuffs to reduce blood flow in arms and legs, and then releasing the affected blood around the body) in people with stroke or those at risk of stroke caused by low blood flow?\ Cochrane Review; 7 trials (735 participants).\ Key results\ In people with narrowing of arteries in the brain, RIC may reduce the risk of recurrent stroke. In people being treated with stenting (the insertion of a metal or plastic tube) for narrowed arteries in the neck, RIC may reduce the size of new brain injuries caused by reduced blood flow. However, its effect on clinical outcomes (stroke and death) was unclear. Adverse events were significantly more common in the RIC group but were not reported to be severe.\ Among people with acute ischaemic stroke (where it had only been several hours from symptom onset) who received clot-dissolving medicines, we found that RIC may increase the risk of death or dependency (needing help from others). We found no significant differences in the size of the final stroke. In people with acute ischaemic stroke and chronic blood vessel disease of the brain, RIC did not affect measures of nerve function, mood, or thinking ability.](https://app.figure1.com/case-detail/a48349c9-f9a3-4e9e-9c13-4f533f6d1446)

Trending now

\ \ A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.\ He had a history of hypertension, long-term smoking, and a sedentary lifestyle.\ On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.](https://app.figure1.com/case-detail/ae0fe999-6875-4474-94f0-ad823dbb9b3a)

\ \ A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.\ Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.](https://app.figure1.com/case-detail/c271070f-2bc7-4052-9895-635277e1a7d5)

\ \ A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.](https://app.figure1.com/case-detail/48f41642-b9db-4089-b120-a94ee52328de)

\ \ patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?](https://app.figure1.com/case-detail/2af390e1-ace8-40ed-ba1c-98fb2d72f4c5)