Abstract：
OBJECTIVE: Guidelines recommend initiation of dual combination antihypertensive therapy, preferably single-pill combination (SPC), in most patients with hypertension. Evidence on narrowing gaps in clinical practice relative to guidelines is limited.
RESULTS: Monte Carlo simulation was applied to 1.1 million patients qualifying for dual combination therapy from a previously conducted retrospective analysis of clinical practice, hospital statistics, and national statistics in the UK. We provide 10-year Kaplan-Meier event rates for the primary endpoint representing a composite of nonfatal myocardial infarction, nonfatal stroke (ischemic or hemorrhagic), nonfatal heart failure hospitalization or cardiovascular death. Cox model results from a previously conducted study were utilized to estimate baseline risk, together with evidence on risk reduction from the Blood Pressure Lowering Treatment Trialists\' Collaboration (BPLTTC) meta-analysis and published evidence on BP-lowering efficacy of antihypertensive therapies. In the overall population, estimated 10-year event rates for the primary endpoint in patients with 100% persistence in monotherapy were 17.0% for irbesartan (I) and 17.6% for ramipril (R). These rates were only modestly better than that observed in clinical practice (17.8%). In patients with 100% persistence in dual therapy, estimated event rates were 13.6% for combinations of Irbesartan + Amlodipine (ARR = 8.7% compared to untreated) and 14.3% for Ramipril + Amlodipine (ARR = 8.0% compared to untreated). The absolute risk of the primary endpoint was reduced by 15.9% in patients with ASCVD and 6.6% in those without ASCVD. Similarly, the absolute risk was reduced by 11.7% in diabetics and 7.8% in those without diabetes.
CONCLUSIONS: This study represents the first to investigate guidelines-based treatment in hypertensive patients and demonstrates the opportunity for considerable risk reduction by ensuring recommended dual therapy in clinical practice, particularly in the form of SPC with high persistence, relative to no treatment or monotherapy.
RESULTS: Monte Carlo simulation was applied to 1.1 million patients qualifying for dual combination therapy from a previously conducted retrospective analysis of clinical practice, hospital statistics, and national statistics in the UK. We provide 10-year Kaplan-Meier event rates for the primary endpoint representing a composite of nonfatal myocardial infarction, nonfatal stroke (ischemic or hemorrhagic), nonfatal heart failure hospitalization or cardiovascular death. Cox model results from a previously conducted study were utilized to estimate baseline risk, together with evidence on risk reduction from the Blood Pressure Lowering Treatment Trialists\' Collaboration (BPLTTC) meta-analysis and published evidence on BP-lowering efficacy of antihypertensive therapies. In the overall population, estimated 10-year event rates for the primary endpoint in patients with 100% persistence in monotherapy were 17.0% for irbesartan (I) and 17.6% for ramipril (R). These rates were only modestly better than that observed in clinical practice (17.8%). In patients with 100% persistence in dual therapy, estimated event rates were 13.6% for combinations of Irbesartan + Amlodipine (ARR = 8.7% compared to untreated) and 14.3% for Ramipril + Amlodipine (ARR = 8.0% compared to untreated). The absolute risk of the primary endpoint was reduced by 15.9% in patients with ASCVD and 6.6% in those without ASCVD. Similarly, the absolute risk was reduced by 11.7% in diabetics and 7.8% in those without diabetes.
CONCLUSIONS: This study represents the first to investigate guidelines-based treatment in hypertensive patients and demonstrates the opportunity for considerable risk reduction by ensuring recommended dual therapy in clinical practice, particularly in the form of SPC with high persistence, relative to no treatment or monotherapy.
摘要：
目的：指南推荐开始双重联合抗高血压治疗，优选单药丸组合(SPC)，在大多数高血压患者中。关于缩小临床实践与指南差距的证据有限。
结果：蒙特卡罗模拟应用于110万名符合双重联合治疗资格的患者，这些患者来自先前进行的临床实践回顾性分析，医院统计,和英国的国家统计数据。我们提供了主要终点的10年Kaplan-Meier事件发生率，代表非致死性心肌梗死的复合终点，非致命性中风（缺血性或出血性），非致命性心力衰竭住院或心血管死亡。先前进行的研究的Cox模型结果用于估计基线风险，结合降血压治疗试验者合作(BPLTTC)荟萃分析和发表的关于降血压治疗疗效的证据,降低风险.在总人口中,在单药治疗持续100%的患者中,估计10年主要终点事件发生率厄贝沙坦(I)为17.0%,雷米普利(R)为17.6%.这些比率仅略高于临床实践中观察到的比率（17.8％）。在100%坚持双重治疗的患者中，厄贝沙坦+氨氯地平组合的估计事件发生率为13.6%(与未治疗相比,ARR=8.7%),雷米普利+氨氯地平的估计事件发生率为14.3%(与未治疗相比,ARR=8.0%).主要终点的绝对风险在ASCVD患者中降低15.9%，在无ASCVD患者中降低6.6%。同样，糖尿病患者的绝对风险降低了11.7%,无糖尿病患者的绝对风险降低了7.8%.
结论：本研究首次对高血压患者进行了基于指南的治疗研究，并通过确保在临床实践中推荐的双重治疗，证明了大大降低风险的机会。特别是以具有高持久性的SPC形式，相对于没有治疗或单一疗法。
结果：蒙特卡罗模拟应用于110万名符合双重联合治疗资格的患者，这些患者来自先前进行的临床实践回顾性分析，医院统计,和英国的国家统计数据。我们提供了主要终点的10年Kaplan-Meier事件发生率，代表非致死性心肌梗死的复合终点，非致命性中风（缺血性或出血性），非致命性心力衰竭住院或心血管死亡。先前进行的研究的Cox模型结果用于估计基线风险，结合降血压治疗试验者合作(BPLTTC)荟萃分析和发表的关于降血压治疗疗效的证据,降低风险.在总人口中,在单药治疗持续100%的患者中,估计10年主要终点事件发生率厄贝沙坦(I)为17.0%,雷米普利(R)为17.6%.这些比率仅略高于临床实践中观察到的比率（17.8％）。在100%坚持双重治疗的患者中，厄贝沙坦+氨氯地平组合的估计事件发生率为13.6%(与未治疗相比,ARR=8.7%),雷米普利+氨氯地平的估计事件发生率为14.3%(与未治疗相比,ARR=8.0%).主要终点的绝对风险在ASCVD患者中降低15.9%，在无ASCVD患者中降低6.6%。同样，糖尿病患者的绝对风险降低了11.7%,无糖尿病患者的绝对风险降低了7.8%.
结论：本研究首次对高血压患者进行了基于指南的治疗研究，并通过确保在临床实践中推荐的双重治疗，证明了大大降低风险的机会。特别是以具有高持久性的SPC形式，相对于没有治疗或单一疗法。
