Key result
Benazepril plus amlodipine cuts major cardiovascular events ~21% vs benazepril plus hydrochlorothiazide in diabetic hypertension.
Why the study?
The antihypertensive combination therapy that most effectively decreases cardiovascular events in patients with both hypertension and diabetes required clarification.
Does combining benazepril with amlodipine compared to benazepril with hydrochlorothiazide reduce cardiovascular events in patients with hypertension and diabetes?
RCT (n=6,946)
randomized to treatment with B+A or B+H
Does combining benazepril with amlodipine compared to benazepril with hydrochlorothiazide reduce cardiovascular events in patients with hypertension and diabetes?
In patients with diabetes and hypertension, combination therapy with benazepril plus amlodipine is superior to benazepril plus hydrochlorothiazide in reducing cardiovascular events.
Supports benazepril-amlodipine over benazepril-hydrochlorothiazide in hypertensive diabetes; challenges thiazide-based regimen preference in guidelines.
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).
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Weber et al. (2010) conducted an RCT in Hypertension and diabetes (n=6,946). Benazepril combined with amlodipine (B+A) vs. Benazepril combined with hydrochlorothiazide (B+H) was evaluated on Composite of cardiovascular death, myocardial infarction, stroke, hospitalization for angina, resuscitated arrest, and coronary revascularization (HR 0.79, 95% CI 0.68 to 0.92, p=0.003). Benazepril plus amlodipine reduced primary composite cardiovascular events compared to benazepril plus hydrochlorothiazide in diabetic patients with hypertension (8.8% vs 11.0%; HR 0.79, p=0.003).
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