Uncontrolled Hypertension with Coronary Artery Disease

Case presentation: Women aged 55 years BP-160/102 mmHg History of stable coronary artery disease Current medication: Metoprolol extended-release (50 mg) + Telmisartan (40 mg) for 4 weeks. Well-tolerated, good compliance; but BP uncontrolled Plan of treatment: For 24 weeks Addition of diuretic to further control BP Telmisartan (40 mg) + Metoprolol extended release (50 mg) + Chlorthalidone (12.5 mg) Primary Outcomes: Mean change in Seated Systolic Blood Pressure (SeSBP) from baseline to 24 weeks. Mean change in Seated Diastolic Blood Pressure (SeDBP) from baseline to 24 weeks. Evaluation of CGI-S from baseline. Evaluation of CGI-I Safety Adverse events Clinically significant improvement in SeSBP and SeDBP with combination Fixed-dose combination of three drugs available Telmisartan (40 mg) + Metoprolol extended release (25/50 mg) + Chlorthalidone (12.5 mg) Use of Single Pill Combination Therapy: The use of a single triple combination tablet will help in controlling BP in patients not adequately responding to dual combination therapy and achieving therapeutic control. European Society of Cardiology (ESC) guidelines suggest that it is better to use drugs in combination in a single pill as it increases patients’ adherence and compliance. It must be a good combination with a good safety profile. Recommendations: Thiazide diuretics, especially chlorthalidone is the preferred drug. Angiotensin-converting receptors are more preferred over angiotensin-converting enzyme inhibitors. Among ARBs, telmisartan is the most commonly used drug. Beta-blockers are used as first-line medications in heart failure, ischemic heart disease, atrial fibrillation. Vasodilators such as hydralazine are not first-line and should only be added when a third or fourth medication is needed. Two or more antihypertensives are needed for uncontrolled hypertension with coronary artery disease. Patients with uncontrolled hypertension with coronary artery disease should be started on two antihypertensive then reassessed for a response to therapy and if not controlled a three-drug single pill should…

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