Sacubitril/valsartan bests olmesartan in elderly Asian patients with hypertension
The angiotensin receptor neprilysin (ARN) inhibitor sacubitril/valsartan provides superior blood pressure (BP)-lowering benefit to elderly Asian patients with systolic hypertension as compared with olmesartan, one of the most widely prescribed angiotensin II receptor blockers (ARBs), according to the results of a 14-week trial.
A total of 588 Asian patients aged ≥65 years (mean 70.7 years) who had a mean sitting (ms) BP of 160.3/84.9 mm Hg and ms pulse pressure (msPP) of 75.4 mm Hg at baseline were initially randomized to receive once-daily sacubitril/valsartan 100 mg (n=296) or olmesartan 10 mg (n=292). The respective treatments were increased to 200 and 20 mg at week 4.
Compared with olmesartan, sacubitril/valsartan afforded greater reductions in the primary endpoint of ms systolic BP at week 10 (22.71 vs 16.11 mm Hg; p<0.001). Other week-10 assessments including changes from baseline in ms diastolic BP, msPP, mean ambulatory (ma) BP and maPP were similarly better with the ARN inhibitor (p<0.001 for all). [Am J Hypertens 2017;doi:10.1093/ajh/hpx111]
At week 14, reductions from baseline in ms systolic BP, ms diastolic BP and msPP were similarly greater in patients treated with sacubitril/valsartan 200 to 400 mg than in those who received olmesartan 20 to 40 mg. This is despite the fact that more patients required up-titration in the olmesartan group (50 vs 36 percent), the investigators noted.
Finally, the proportion of patients who achieved BP control (<140/90 mm Hg) in the sacubitril/valsartan group was significantly greater than in the olmesartan group at week 4 (47.5 vs 41.2 percent; p=0.045), week 10 (59.3 vs 44.7 percent; p<0.001) and week 14 (58.6 vs 43.3 percent; p<0.001).
Of the patients, 91.9 percent in the sacubitril/valsartan group and 93.5 percent in the olmesartan group completed the study. Ambulatory blood pressure monitoring data was available in 154 and 157 patients, respectively. Both treatments were generally well tolerated, with adverse events reported at a frequency of ≥2.0 percent in either group.
The investigators pointed out that despite the presence of limitations including the use of PP as a surrogate marker for arterial stiffness, the study demonstrates that sacubitril/valsartan may represent an effective therapeutic approach for treating systolic hypertension in elderly Asian patients, in whom BP is more variable.
“In such patients, ambulatory BP monitoring provides a more realistic method of assessing the effects of an antihypertensive agent than office [or sitting] BP,” they added.
The present data also add to the body of evidence showing that sacubitril/valsartan effectively reduces clinic and ambulatory central aortic and brachial pressures as compared with olmesartan in elderly patients with systolic hypertension and stiff arteries (PARAMETER trial), as well as cuts the risk of cardiovascular death, heart failure (HF) hospitalization and all-cause death as compared with enalapril across all age groups of patients with HF (PARADIGM-HF trial). [Hypertension 2017;69:411–420; Eur Heart J 2015;36:2576–2584]