Individuals with hypertension have higher lifetime risks for cardiovascular disease (CVD) and experience the onset of CVD morbidity five years earlier than individuals with normal BP. Among middle-aged adults, every 20mmHg increase in systolic blood pressure (SBP) is associated with a doubling in the rate of death resulting from stroke, ischaemic heart disease, and other vascular causes.
Not only is grade 1 hypertension common among young and middle-aged adults, but the majority of these individuals will progress to stage 2 hypertension, with an even higher risk of atherosclerotic CVD. Yano et al demonstrated that adults with elevated BP or grade 1 hypertension had CVD event rates ≈70% higher than those with a normal BP.
According to the 2020 International Society of Hypertension Global Hypertension Practice Guidelines, if there is an established diagnosis of hypertension, give lifestyle advice. Grade 1 hypertension is defined as systolic BP 140-159mmHg and diastolic BP 90-99mmHg. Provide immediate drug treatment in high-risk patients and those with CVD, Chronic kidney disease (CKD), diabetes mellitus (DM) or hypertension-mediated organ damage (HMOD). It is optimal to have drug treatment in low-to-moderate-risk patients without CVD, CKD, DM or HMOD after 3-6 months of lifestyle intervention, if BP is still not controlled.
Initial monotherapy is successful in many patients with mild primary hypertension. However, single-drug therapy is unlikely to attain goal blood pressure in patients whose blood pressures are more than 20/10mmHg above goal. In such patients, initial combination therapy using two drugs is recommended.
RAS blockers, beta-blockers irrespective of BP levels with or without calcium channel blockers (CCBs) are first-line drugs in hypertensive patients. The hypertension guidelines recently issued in the United States and Europe now advise the initial use of two antihypertensive drugs in most hypertensive patients. This is because new evidence has shown that initial combination treatment not only extends to an earlier time window the protection of high cardiovascular risk individuals but it has additional short-term and even long-term advantages in the more general hypertensive population. Initial use of two antihypertensive drugs is followed not only by a prompter BP reduction but also by a reduced heterogeneity of the BP response between patients. It is characterised by a steeper relationship between the doses of the combination components used and the BP effect that makes subsequent uptitration of treatment easier, faster, and more frequently successful. Except for some hypertension categories, such as the elderly and the frail, older patients, the risk of excessive hypotension is only slightly greater than that accompanying initial monotherapy or placebo even in patients with a modest initial BP elevation (grade 1 hypertension) as documented by a recent randomised trial.
Most importantly, evidence has been obtained that initial combination treatment may be associated with long-term advantages of crucial clinical relevance that appear to involve the hypertensive population at large. Recent evidence is also available that, compared with initial monotherapy, initial 2-drug combination treatment can effectively bypass therapeutic inertia and the amount of BP reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension. Careful attention to adherence issues should be given to young adults with stage 1 hypertension to prevent further CVD complications later on in life.
References available on request.