Dispelling the myth of "aggressive" antihypertensive therapy.

Data from well designed randomized trials have proven the effectiveness of an intensive approach to hypertension management in reducing morbidity and mortality. Based on these data, guidelines recommend a blood pressure goal of <140/90 mm Hg in the general population, with lower goals for high-risk patients. Clinical trials also show that most patients will require at least two antihypertensive agents to reach goal. Despite this evidence base, only about one third of individuals with hypertension receive sufficient therapy to attain a blood pressure of <140/90 mm Hg. Physicians may be reluctant to use multiple antihypertensive agents to achieve this goal because they may consider it to be "aggressive" and not always in the best interests of the patient, especially in those deemed at low risk. Such perceptions may be founded on several myths: 1) the approach demands a complex, time-consuming titration-to-response strategy, during which the patient may be lost to follow-up; 2) it increases the pill burden, which will decrease patient compliance; 3) it increases treatment-related side effects; and 4) it is not cost-effective. The availability of fixed-dose combinations containing two antihypertensive agents should help to dispel these myths. Careful selection of efficacious, well tolerated, once-daily, fixed-dose combinations allows goal blood pressure to be achieved quickly in a broad range of patients and encourages patient concordance with therapy. Such formulations are also cost-effective. Thus, reducing blood pressure using multiple drugs as fixed-dose combinations is a strategy that recognizes the multiple pathophysiologic changes that lead to hypertension.