Introduction:
Cumulative exposure to hypertension is an adverse prognostic marker. However longitudinal assessments of blood pressure (BP), i.e. TIme at TaRgEt (TITRE), are not routinely assessed in practice. Specifically, the effect of low-dose combination anti-hypertensive therapy on TITRE has not been studied.
Hypothesis:
Low-dose triple combination antihypertensive medication achieves greater TITRE compared to usual care.
Methods:
TRIUMPH (TRIple pill vs Usual care Management for Patients with mild-to-moderate Hypertension) was a randomized controlled open-label trial of patients requiring initiation or escalation of antihypertensive therapy. Patients from urban hospital clinics in Sri Lanka were randomised to either once-daily low-dose triple combination polypill (20mg of telmisartan, 2.5mg of amlodipine, and 12.5mg of chlorthalidone) or standard care. This analysis compared TITRE in the intervention and usual care groups over 6 months follow-up, with TITRE defined as percentage of time at target BP. Target BP was defined as <140/90mmHg or <130/80mmHg in patients with diabetes or chronic kidney disease.
Results:
The trial comprised 700 patients (mean [±SD] age: 56±11 years, 58% women). Patients in the triple pill group (n=349) achieved a higher TITRE compared to those in the standard care group (n=351) at 6 months (64±32% vs 43±34%, risk difference -21%, 95%CI -26% to -6%, p<0.001). Almost twice as many patients in the triple pill group spent the majority of follow-up time at target (TITRE >50%: 64% vs 37%, p<0.001). The effect of the triple pill was seen early, with the majority achieving TITRE >50% by 12 weeks. Those on the triple pill achieved a consistently higher TITRE at all follow-up periods compared to usual care (0-6 weeks: 36±31% vs 21±28%; 6-12 weeks: 74±39% vs 46±43%; 12-24 weeks: 77±37% vs 53±44%, all p<0.001). When predictors of TITRE were examined, only triple pill therapy was predictive of TITRE >75% (odds ratio [OR] 3.41, 95%CI 2.30-5.04, p<0.001).
Conclusion:
Among patients with mild-moderate hypertension, treatment with a low-dose triple combination pill significantly increased time at target compared to usual care. This study also introduces TITRE as a novel outcome assessing longitudinal BP control in trials.
Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka
