I Want More, More, More…Blood Pressure and Cholesterol Lowering

Volume 8, Issue 1

Billy Idol’s famous 1983 smash hit etched one of the most recognizable song lyrics into our collective idiom—more, more, more. For patients with established cardiovascular diseases, or for those with excessive risk factors, there is often a perpetual cry for “more” blood pressure and cholesterol control.

In this week’s issue of Talking Therapeutics, we look at two recently published papers that shed light on the optimal amount of “more” for these patients in search of reducing residual cardiovascular risk.

Point 1: Do Two Drugs Lower Blood Pressure More Than One?

When managing hypertension, clinical equipoise exists for patients uncontrolled on sub-maximal doses of single-drug therapy. Some advocate for maxing out existing drugs first, whereas others recommend adding another drug before maxing out existing therapy.

A study from a large veterans database explored these two theories and found that found that while fewer patients at 3 months adhered to the added agent, the addition of another antihypertensive reduced systolic blood pressure significantly more by an extra 0.8 mm Hg at 3 months and by 1.1 mm Hg more at 12 months than dose maximization (-5.6 vs -4.5 mm Hg). Based on the findings, it would see that adding another medication is more effective at lowering blood pressure, but few patients persist in taking the added medications.

Perhaps in this context, less is “more.”

Point 2: Two Drugs Are Better at Lowering LDL

For patients with residual hyperlipidemia (elevated LDL) despite optimal statin therapy, addition of either a PCSK9 inhibitor or eztimibe can help to achieve lipid goals and reduce residual cardiovascular risk. But what about combination therapy in patients whose LDL is at “goal?”

An analysis of the IMPROVE-IT trial published this week found that adding ezetimibe to moderate-intensity statin therapy reduces the risk of major cardiovascular events in post-ACS patients across the range of baseline LDL-cholesterol levels, including those with values less than 70 mg/dL. The analysis supports the European Society of Cardiology guidelines that recommend targeting LDL levels less than 55 mg/dL in high-risk patients with atherosclerotic cardiovascular disease; these recommendations currently contrast the ACC/AHA guidelines that limit additional lipid-lowering therapy to high-risk patients with LDL-cholesterol levels exceeding 70 mg/dL.

In the context of lipid lowering therapy, it seems that more may be “more.”

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