The main advantage of sartans is a very good safety profile. Now it is about increasing adherence in hypertensive patients
The rules for initiating hypertension treatment have been simplified. The trend is to achieve blood pressure control as early as possible, making it unnecessary to wait for a longer period for the effect of non-pharmacological measures. One of the 4 main classes of antihypertensives is AT1 receptor blockers for angiotensin II – sartans, which bring several advantages. These include a low incidence of side effects, a good antihypertensive effect, or the possibility of use in fixed combinations. We will take a closer look at the current position of sartans in the treatment of hypertension with Assoc. Prof. Ondřej Petrák, MD, PhD, from the Center for Research, Diagnosis, and Treatment of Hypertension at the 3rd Internal Clinic - Clinic of Endocrinology and Metabolism at the 1st Faculty of Medicine, Charles University in Prague, and General University Hospital in Prague.
Last year, updated „Diagnostic and Therapeutic Procedures for Arterial Hypertension“ by the Czech Society for Hypertension (ČSH) were published. Can you summarize the main changes these recommendations brought?
We tried to simplify the current recommendations to make them clear and concise guides for doctors on how to proceed, diagnose, and treat. Most foreign guidelines are unnecessarily extensive and become practically unreadable. I firmly believe that the ČSH recommendations are well understandable. We simplified some procedures – for example, when to start treatment, how to determine cardiovascular risk, or how to proceed in combination therapy for hypertension. There are changes in the section on non-pharmacological approaches, especially concerning physical activity. We added some procedures for specific situations, such as the treatment of hypertension during hospitalization, in people with sympathicotonia and higher heart rates, in patients with chronic obstructive pulmonary disease (COPD) or bronchial asthma, or the approach to paroxysmal hypertension.
When should hypertension treatment be initiated?
The rules for initiating hypertension treatment have been simplified. The trend is to achieve blood pressure control as early as possible, making it unnecessary to wait for a longer period for the effect of non-pharmacological measures. Today, we start treatment immediately with BP in the range of moderate to severe hypertension, meaning values higher than 160 mmHg systolic and/or 100 mmHg diastolic pressure in the office. In the case of mild hypertension, it is recommended to start treatment within 1 to 3 months. At the same time, I would recommend verifying the severity of hypertension by 24-hour blood pressure monitoring.
What is the current treatment goal?
The treatment goal hasn't changed. The main aim is to reduce the risk of cardiovascular events. In numerical terms, this means reducing clinical pressure below 140/90 mmHg for everyone and optimally achieving values around 130/80 mmHg. Similarly, we can consider values below 130/80 mmHg during 24-hour blood pressure measurement and lower than 135/85 mmHg during home measurement as equivalents.
What drugs and combinations should be chosen optimally?
We still have 4 main classes of antihypertensives available. They are considered main classes because we have sufficient evidence for their positive effects in the form of morbidity-mortality studies. These include the class of renin-angiotensin-aldosterone system (RAAS) inhibitors, namely angiotensin-converting enzyme inhibitors (ACEi) and sartans, calcium channel blockers (CCB), thiazide and thiazide-like diuretics, and beta-blockers. Drugs from secondary classes are used only if blood pressure cannot be controlled with the main ones.
In hypertension treatment, we prefer combination therapy, ideally fixed. The only exception where we should be more cautious and start with monotherapy is in elderly and frail patients or individuals with mild hypertension and low cardiovascular risk. A suitable combination with the broadest spectrum of use is the combination of an ACEi or sartan with a CCB. The second choice is the combination of an ACEi or sartan with a diuretic. However, we always individualize the treatment according to the patient's age, gender, and other comorbidities.
What is the specific role of sartans in hypertension treatment?
We have enough evidence to show that their administration helps patients, reduces cardiovascular risk, and prolongs their lives. Generally, together with ACEi, they rank high in the treatment of arterial hypertension and other comorbidities such as ischemic heart disease (IHD), heart failure, atrial fibrillation, chronic renal insufficiency, and metabolic syndrome.
How do sartans compare to other antihypertensives?
They have a significant advantage in terms of safety profile, being among the best-tolerated antihypertensives with no specific adverse effects. Certainly, we won't go wrong if we choose a sartan in treating hypertension, either alone or in a fixed combination with another antihypertensive. Moreover, compared to other classes like diuretics and beta-blockers, they have a markedly positive metabolic effect and do not worsen glucose metabolism and blood lipids.
How big of a problem is patient non-adherence in the treatment of hypertension, and what does it lead to?
Not taking medications is a big problem. Since we are treating an asymptomatic disease, it is sometimes difficult for the patient to understand the need for long-term treatment. Adherence drops sharply in the first year from initiation. Here, the attending physician's ability to adequately motivate the patient and explain the benefits of taking medications and controlling blood pressure is undeniable. We have found that adherence is directly proportional to the patient's achieved education and social status. The consequences of not taking treatment can often be disabling, especially in the case of hemorrhagic and ischemic cerebrovascular accidents.
What are the advantages of sartans in addressing and preventing non-adherence?
We generally try to improve adherence to therapy by all available means – education, simplification of the treatment regimen, and minimization of the number of tablets through fixed combinations. Sartans offer several advantages – low incidence of side effects, very good antihypertensive effect, and fixed combinations with both CCB and diuretics. We even have fixed triple combinations available. These combinations not only complement each other beneficially in terms of antihypertensive effect but also reduce the risk of developing certain additional side effects (such as edema with CCB use or hypokalemia induced by diuretics).
How can we further improve the outlook for patients with hypertension?
Here, every piece of advice is valuable. Personally, I would like to remind that not every hypertension is essential, and we must not forget the possibility of secondary etiology. Some of these causes, such as primary hyperaldosteronism or pheochromocytoma, are often fully curable without the need for long-term antihypertensive treatment. However, in the case of essential hypertension, we currently have no prospect of permanent cure, and all instrumental non-pharmacological procedures like renal denervation have failed. We are left with rationally chosen pharmacological treatment and a healthy lifestyle.
Andrea Skálová, MD
proLékaře.cz editorial team
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