3 Monotherapy vs. Combination Therapy The previous 2007 ESH/ESC guidelines stressed that most patients would require more than one antihypertensive drug to achieve their BP target. Conversely, the updated 2013 guidelines present a more balanced discussion of the advantages and disadvantages of initiating hypertensive patients on monotherapy vs. combination therapy. Initiating monotherapy allows clear determination of the drug’s efficacy and tolerability, while one of the agents may be ineffective

with combination therapy. Monotherapy has a clear place in the treatment algorithm, especially for grade 1 or mild hypertension [42]. However, when monotherapy is insufficient or poorly tolerated, finding an alternative monotherapy that is more effective and/or better tolerated can be difficult and may discourage PD0332991 ic50 adherence. Escalating the dosage of a prescribed monotherapy may be less effective for BP reduction than combining agents from different antihypertensive classes [43]. Combination therapy allows a more prompt BP response vs. up titration of monotherapy, has a Selleck LDN-193189 greater probability of achieving target BP in patients with a higher BP, and may encourage patient adherence [2]. Compared with monotherapy, combining Ilomastat order antihypertensive drugs also lowers the incidence

of major CV events (stroke and ischemic heart disease) [6] and initiating low-dose combination therapy may have greater CV benefits than starting on monotherapy [44]. Additionally, combination of certain classes of antihypertensive agents has a fully additive effect, allowing earlier, larger, and more sustained reductions in BP than up titration of monotherapy and a sequential add-on regimen [44]. The 2013 ESH/ESC guidelines reconfirm the importance of initiating

combination therapy in high-risk patients and those with markedly high baseline BP [2], with initial combination therapy generally recommended for patients with SBP/DBP >15–20/>10 mmHg above the target [44]. 3.1 Choice of Antihypertensive Agent All classes of antihypertensive agent recommended for monotherapy by the different international societies are shown in Table 3 [2–4, 23–25, 45]. Overall, the five main classes of antihypertensive agents (ACE inhibitors, ARBs, β-blockers, CCBs, and thiazide diuretics) have comparable clinical efficacy as Vitamin B12 monotherapy [6, 7, 9]. However, β-blockers are losing favor as recommended initial therapy for most patients because of questions about their efficacy in preventing stroke and other CV events, and their adverse effects on glucose metabolism [3, 4]. In contrast, CCBs have been cleared of the suspicion of increasing the incidence of coronary events [2, 5] and these agents have been reported to exhibit the lowest inter-individual variation in SBP vs. other antihypertensive classes, which may be linked to a reduced risk of stroke [6–8, 46]. However, these data require confirmation in future trials.