CCB plus ARB Improves Outcomes in Hypertension and CKD

In high-risk older adults with hypertension and chronic kidney disease (CKD), adding a calcium channel blocker (CCB) to high-dose angiotensin II receptor blockade (ARB) yields further reductions in cardiovascular events, reports a trial in Kidney International.

The multicenter “OlmeSartan and Calcium Antagonists Randomized” (OSCAR) trial included 1078 older Japanese adults with hypertension and baseline cardiovascular disease and/or diabetes. In the main trial, patients were randomly assigned to upward titration of ARB or to the addition of a CCB to ARB therapy. The current study was a prespecified subgroup analysis assessing treatment responses according to baseline estimated GFR (eGFR).

On the basis of an eGFR of less than 60 mL/min/1.73 m2, 353 patients had CKD; in almost all, eGFR was 30–59 mL/min/1.73 m2. In patients with or without CKD, blood pressure was lower with CCB plus ARB than with high-dose ARB.

Among CKD patients, the primary composite outcome of cardiovascular events and noncardiovascular death was about twice as high in the high-dose ARB group: 30 versus 16 events, hazard ratio 2.25. In particular, the rates of cerebrovascular and heart failure events were higher in CKD patients receiving high-dose ARB, compared with CCB plus ARB. By contrast, for patients without CKD, the primary event rate was similar between treatment groups. The subgroup interaction was significant, with high-dose ARB being an independent prognostic factor for primary events among patients with CKD.

High-dose ARB therapy lowers the rate of cardiovascular and renal events in certain high-risk groups of patients with hypertension. The combination of an ARB with a CCB is a recommended treatment for the general hypertensive population.

This OSCAR subgroup analysis suggests that ARB plus CCB is more effective than high-dose ARB for elderly high-risk patients with CKD. In this group, the combination yields a lower risk of cardiovascular events, particularly stroke and heart failure. The results lend new insights for decisions about antihypertensive therapy for older adults with CKD [Kim-Matsuyama S, et al. An angiotensin II receptor blocker–calcium channel blocker combination prevents cardiovascular events in elderly high-risk hypertensive patients with chronic kidney disease better than high-dose angiotensin II receptor blockade alone in hypertensive patients with diabetic nephropathy. Kidney Int 2013; 83:167–176].

February 2013 (Vol. 5, Number 2)