Triple Combination Pill Shows Substantial Increase in Time at Target Blood Pressure

Anthony Rodgers, PhD

New findings suggested treatment with a low-dose triple combination pill of telmisartan 20 mg, amlodipine 2.5 mg, and chlorthalidone 12.5 mg was associated with substantially higher time at blood pressure (BP) target among patients with mild to moderate hypertension.

Data show the higher time at BP target ranged from 64% in the triple pill group (n = 349) to 43% in the usual care group (n = 351) over 24 weeks’ follow-up (risk difference, 21%; 95% CI, 16 - 26; P <.001).

“Treatment effects appeared to be larger than those suggested by the main trial primary outcome at 24 weeks, as time at target captured the benefits of both reduced time to BP control and more sustained BP control with low-dose triple pill therapy,” wrote study author Anthony Rodgers, PhD, The George Institute for Global Health, University of New South Wales.

Rodgers and colleagues noted time at target incorporated systolic and diastolic BP, multiple time points, and BP targets in a single metric that is consistent and understandable, which may serve as an advantage over other metrics. However, the effect of any intervention, including single pill combination antihypertensive therapy, on time at target has not been examined or used as an outcome in randomized clinical trials.

Thus, a post hoc analysis of the Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) randomized clinical trial evaluated whether triple pill therapy was associated with an increased time at target, compared to usual care, at 11 urban hospital outpatient departments in Sri Lanka.

The primary outcome was considered time at target, with target BP defined as per protocol as systolic BP ≤140 mm Hg and/or diastolic BP ≤90 mm Hg or systolic BP ≤130 mm Hg and/or diastolic BP ≤80 mm Hg in patients with diabetes or chronic kidney disease.

Between-group differences in time at target were compared over 24 weeks of follow-up, with time at target defined as percentage of time at target BP.

A total of 700 individuals in the trial were monitored for 24 weeks, with a mean age of 56.2 years and 403 participants (57.6%) were women. Data show the mean baseline BP was 154/90 mm Hg and 287 participants (41.0%) were receiving antihypertensive therapy pre randomization.

Patients in the triple pill group (n = 349) had higher time at target compared with those in the usual care group (n = 351) over 24 weeks’ follow-up (64% vs 43%; risk difference, 21%; 95% CI, 16 - 26; P <.001).

Further, those in the triple group achieved more than 50% time at target during follow-up compared with usual care (time at target >50% - 75%, 29.2% vs 21.4; x2, 5.38; P = .02 and time at target >75%, 34.8% vs 15.1%; x2, 35.58; P <.001).

Investigators noted the early association of time at target with triple pill therapy, with most patients achieving more than 50% time at target by 12 weeks.

In fact, the triple pill group achieved a consistently higher time at target at all follow-up periods compared with usual care (mean, 0 - 6 weeks, 36.3% 36.3% [30.9%] vs 21.7% [28.9%]; P < .001; 6 - 12 weeks, 5.2% [31.9%] vs 33.7% [33.0%]; P < .001; 12 - 24 weeks, 66.0% [31.1%] vs 43.5% [34.3%]; P < .001).

“Further research is needed to explore the optimal frequency of BP measurements required for time at target calculations and whether longitudinal BP assessment provides superior prediction of clinical outcomes compared with current cross-sectional definitions,” Rodgers concluded.

The study, “Association of Low-Dose Triple Combination Therapy vs Usual Care With Time at Target Blood Pressure: A Secondary Analysis of the TRIUMPH Randomized Clinical Trial,” was published in JAMA Cardiology.