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ACCOMPLISH: ACE Inhibitor Plus Calcium-Channel Blocker Best for Reducing Clinical Events in Hypertensive Patients CME

News Author: Michael O'Riordan
CME Author: Désirée Lie, MD, MSEd
Disclosures

Release Date: April 1, 2008; Valid for credit through April 1, 2009

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians; Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

From American College of Cardiology (ACC) 57th Annual Scientific Session

From Heartwire — a professional news service of WebMD

April 1, 2008 (Chicago) — New data from the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial were presented today at the American College of Cardiology 2008 Scientific Sessions [1]. They showed that a single-tablet dual-mechanism therapy initiated in high-risk hypertensive patients significantly reduced the risk of morbidity and mortality by 20% compared with conventional therapy.

ACCOMPLISH, a major morbidity and mortality trial, compared the effects of two forms of antihypertensive combination therapies on major fatal and nonfatal cardiovascular events. It was stopped early because treatment with antihypertensive combination therapy — the angiotensin-converting enzyme (ACE) inhibitor benazepril plus the calcium-channel blocker amlodipine — was more effective than treatment with the ACE inhibitor plus diuretic.

Lead investigator Dr Kenneth Jamerson (University of Michigan, Ann Arbor), who presented the results of the study during the late-breaking clinical-trials session, said he was "absolutely thrilled" to present the findings of a study designed to challenge current guidelines in defining the optimal strategy for blood-pressure control and preventing cardiovascular events in high-risk patients.

"If you use the combination of a calcium-channel blocker with an ACE inhibitor, you get exquisite blood-pressure control," said Jamerson, who added that similar control was observed with the ACE inhibitor and diuretic. Despite the similar blood pressure, the combination with the calcium-channel blocker and ACE inhibitor reduced cardiovascular morbidity and mortality 20%.

During a press conference announcing the results, Jamerson told the media that the findings are "paradigm-shifting" and the data are a clear win with a clear message. He said the ACCOMPLISH findings challenge the guidelines, especially in terms of starting with a one-drug strategy and the use of diuretics in combination with ACE inhibitors.

Clear data, clear win, and a clear message

Current recommendations for the treatment of stage 1 hypertension include the use of thiazide-type diuretics for most patients, with additional consideration given to ACE inhibitors, angiotensin-receptor blockers (ARBs), beta blockers, and calcium-channel blockers. In patients with stage 2 hypertension — those with blood pressure ≥ 160/≥ 100 mm Hg — two-drug combination therapy, usually with a diuretic and ACE inhibitor, is recommended.

ACCOMPLISH compared the effects of two forms of antihypertensive combination therapies on major fatal and nonfatal cardiovascular events. In total, 11,400 men and women aged 55 years or older who had systolic blood pressure ≥ 160 mm Hg or were currently on antihypertensive therapy and who had evidence of cardiovascular or renal disease or target-organ damage were included in the trial. Patients enrolled in the trial were obese, with 60% having diabetes mellitus, and nearly all had been treated previously for hypertension.

More than 70% had been treated with two or more hypertensive agents, but, as was previously reported by heartwire at the American Society of Hypertension 2007 Scientific Sessions, just 37.5% of patients had their blood pressure controlled to <>Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. As part of the study protocol, all patients stopped their medication and, without a washout period, were randomized to combination treatment with benazepril plus hydrochlorothiazide or amlodipine plus benazepril.

At 36 months, blood-pressure levels were significantly improved, with more than 75% of patients in both treatment arms having blood-pressure levels <>

ACCOMPLISH: Primary* and secondary end points

End point	Hazard ratio (95% CI)
*Cardiovascular morbidity/mortality	0.80 (0.71 - 0.90)
Cardiovascular morbidity/mortality (excluding coronary revascularization)	0.79 (0.68 - 0.92)

Speaking with the media, Jamerson noted that the average patient in the study was 68 years old, and the oldest patient was 98 years old. Although hypotension might be a concern and can result in falls and fractures in elderly patients or in the frail, this was not borne out in the ACCOMPLISH study.

Dr Michael Weber (SUNY Downstate Medical Center, Brooklyn, NY), who was on the executive committee of the ACCOMPLISH trial, agreed with Jamerson, telling heartwire that the findings will change the guidelines.

"Right now, there is a recommendation that when you're putting together combination treatment for hypertension you need to normally include a diuretic as one of the two agents," said Weber. "I'm sure that recommendation will change. It might not change to the point of stating that a calcium-channel blocker like amlodipine be the preferred partner, but it will take away the recommendation for diuretics, and adding the calcium-channel blocker will invariably be a part of that."

Dr Salim Yusuf (McMaster University, Hamilton, ON) said the study "looks good" but held back full praise until the complete findings are published. He agreed, though, that, based on the presented data, the ACCOMPLISH study will challenge current guidelines.