HYPERTENSION
Cardiovascular Events During Differing Hypertension Therapies in Patients With Diabetes
Michael A. Weber, MD*,*,
George L. Bakris, MD ,
Kenneth Jamerson, MD ,
Matthew Weir, MD ,
Sverre E. Kjeldsen, MD||,
Richard B. Devereux, MD¶,
Eric J. Velazquez, MD#,
Björn Dahlöf, MD**,
Roxzana Y. Kelly, MS,
Tsushung A. Hua, PhD,
Allen Hester, PhD,
Bertram Pitt, MD for the ACCOMPLISH Investigators
* Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, New York
Hypertensive Diseases Unit, Department of Medicine, University of Chicago–Pritzker School of Medicine, Chicago, Illinois
University of Michigan Health System, Ann Arbor, Michigan
University of Maryland School of Medicine, Baltimore, Maryland
|| Ullevaal University Hospital, Oslo, Norway
¶ Cardiology Division, Weill Cornell Medical College, New York, New York
# Duke University School of Medicine, Durham, North Carolina
** Sahlgrenska University Hospital, Gothenburg, Sweden
Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
Manuscript received November 11, 2009;
revised manuscript received February 9, 2010,
accepted February 15, 2010.
* Reprint requests and correspondence: Dr. Michael A. Weber, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Box 97, Brooklyn, New York 11203 (Email: michaelwebermd{at}cs.com).
Objectives: The aim of this study was to determine which combination therapy in patients with hypertension and diabetes most effectively decreases cardiovascular events.
Background: The ACCOMPLISH (Avoiding Cardiovascular Events Through COMbination Therapy in Patients Living With Systolic Hypertension) trial compared the outcomes effects of a renin-angiotensin system blocker, benazepril, combined with amlodipine (B+A) or hydrochlorothiazide (B+H). A separate analysis in diabetic patients was pre-specified.
Methods: A total of 6,946 patients with diabetes were randomized to treatment with B+A or B+H. A subgroup of 2,842 diabetic patients at very high risk (previous cardiovascular or stroke events) was also analyzed, as were 4,559 patients without diabetes. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, hospitalization for angina, resuscitated arrest, and coronary revascularization.
Results: In the full diabetes group, the mean achieved blood pressures in the B+A and B+H groups were 131.5/72.6 and 132.7/73.7 mm Hg; during 30 months, there were 307 (8.8%) and 383 (11.0%) primary events (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92, p = 0.003). For the diabetic patients at very high risk, there were 195 (13.6%) and 244 (17.3%) primary events (HR: 0.77, 95% CI: 0.64 to 0.93, p = 0.007). In the nondiabetic patients, there were 245 (10.8%) and 296 (12.9%) primary events (HR: 0.82, 95% CI: 0.69 to 0.97, p = 0.020). In the diabetic patients, there were clear coronary benefits with B+A, including both acute clinical events (p = 0.013) and revascularizations (p = 0.024). There were no unexpected adverse events.
Conclusions: In patients with diabetes and hypertension, combining a renin-angiotensin system blocker with amlodipine, compared with hydrochlorothiazide, was superior in reducing cardiovascular events and could influence future management of hypertension in patients with diabetes. (Avoiding Cardiovascular Events Through COMbination Therapy in Patients Living With Systolic Hypertension [ACCOMPLISH]; NCT00170950)
Key Words: amlodipine • coronary events • diabetes • hydrochlorothiazide • hypertension
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | B+A = benazepril plus amlodipine | | B+H = benazepril plus hydrochlorothiazide | | HR = hazard ratio | | RAS = renin-angiotensin system |
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