Combination Angiotensin-Receptor Blocker (ARB)/Calcium Channel Blocker With HCTZ vs the Maximal Recommended Dose of an ARB With HCTZ in Patients With Stage 2 Hypertension: The Exforge As Compared to Losartan Treatment in Stage 2 Systolic Hypertension (EXALT) Study


Richard F. Wright, MD, Pacific Heart Institute, 2001 Santa Monica Boulevard, Suite 280 West, Santa Monica, CA 90404


J Clin Hypertens (Greenwich). 2011;13:588–597.

This study compared the efficacy and safety of combination angiotensin-receptor blocker (ARB)/calcium-channel blocker (CCB) with hydrochlorothiazide (valsartan/amlodipine/HCTZ 160/5/25 mg) vs maximal available combination doses of an ARB with HCTZ (losartan/HCTZ 100/25 mg) in the management of stage 2 hypertension. After 1 to 2 weeks of antihypertensive drug washout, patients with a mean sitting systolic blood pressure (MSSBP) of ≥160 mm Hg and <200 mm Hg were randomized to valsartan/amlodipine 160/5 mg (n=241) or losartan 100 mg (n=247). At week 3, HCTZ 25 mg was added to both treatments. The primary end point, reduction in MSSBP from baseline to week 6, was significantly greater in the valsartan/amlodipine group than in the losartan group (least-squares [LS] mean change, −31.8 mm Hg vs −26.4 mm Hg; P<.001). Additional reductions occurred after titrating to 320/10/25  mg at week 6 in the valsartan/amlodipine group and switching from losartan/HCTZ to valsartan/amlodipine/HCTZ (week 6, 160/5/25 mg; week 9, 320/10/25 mg) in the losartan group. Achievement of blood pressure <140/90  mm Hg also favored the valsartan/amlodipine group. Dizziness was the only adverse event reported in >5% of patients (5.4% valsartan/amlodipine group, 3.6% losartan group). Moderate doses of an ARB/CCB combination with HCTZ reduced blood pressure more effectively than the maximal dose of an ARB with HCTZ.