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ACE-inhibitor plus calcium-channel blocker combination safest

Combining an ACE inhibitor with a calcium channel blocker more effectively reduces the risk of cardiovascular events than an ACE inhibitor with a diuretic, a major new trial concludes.

ACCOMPLISH was stopped early after finding clear benefits for the calcium channel blocker combination, and the results were published in the New England Journal of Medicine last week.

Current guidance from NICE and the British Hypertension Society recommends combining a calcium channel blocker or a diuretic with an ACE inhibitor as second-line treatment of hypertension, but the best combination has not been established.

But the ACCOMPLISH study, of more than 11,000 hypertensive patients at high risk of cardiovascular events, found treatment with an ACE inhibitor plus a calcium-channel blocker produced better outcomes than an ACE inhibitor plus a diuretic.

Mean blood pressure in the calcium channel blocker group was 131.6/73.3 mmHg, compared with 132.5/74.7 mm Hg in the diuretic group.

The calcium channel blocker group also had fewer recorded adverse events, with a total of 552 (9.6%), compared with 679 (11.8%) with the diuretic.

Patients treated with an ACE inhibitor and a calcium channel blocker were 21% less likely to suffer a cardiovascular disease-related death or non-fatal heart attack or stroke than those in the diuretic group.

Researchers randomised patients to receive either benazepril plus amlodipine or benazepril plus hydrochlorothiazide, and followed them up for an average of 30 months before the trial was stopped early by a safety committee.

Study leader Professor Kenneth Jamerson, professor of cardiovascular medicine from the University of Michigan Health System, said the high rates of blood pressure control achieved in the ACE inhibitors and calcium channel blocker group were ‘compelling'.

He concluded: ‘Our trial shows combination therapy with benazepril and amlodipine results not only in excellent blood pressure control but also in a clear benefit with respect to cardiovascular outcomes.'

New England Journal of Medicine 2008; 359: 2417-28

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