Vnitr Lek 2026, 72(5):320-324 | DOI: 10.36290/vnl.2026.060

Initiating antihypertensive treatment with combination therapy: why it should become standard practice in most patients

Eva Kociánová ORCID...
I. interní klinika - kardiologická, Fakultní nemocnice Olomouc a Lékařská fakulta Univerzity Palackého v Olomouci

Contemporary hypertension guidelines have shifted from stepwise escalation of monotherapy toward earlier use of combination treatment. The rationale is not limited to greater blood pressure-lowering efficacy; it also includes shortening exposure to uncontrolled blood pressure, reducing therapeutic inertia, and improving adherence. The 2024 ESC and 2023 ESH guidelines prefer an initial low-dose two-drug combination, ideally as a single-pill combination, in most patients with confirmed hypertension; the 2025 AHA/ACC guideline recommends two first-line agents for stage 2 hypertension. Monotherapy remains appropriate in selected situations, particularly in patients with lower blood pressure levels, frailty, symptomatic orthostatic hypotension, or reduced treatment tolerance. This review summarizes the clinical and practical rationale for initial combination therapy and discusses the risks related to persistent use of monotherapy.

Keywords: adherence, arterial hypertension, blood pressure target, combination therapy, monotherapy, single-pill combination, therapeutic inertia.

Accepted: August 20, 2026; Published: August 27, 2026  Show citation

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Kociánová E. Initiating antihypertensive treatment with combination therapy: why it should become standard practice in most patients. Vnitr Lek. 2026;72(5):320-324. doi: 10.36290/vnl.2026.060.
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    References

    1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957-980. Go to original source... Go to PubMed...
    2. Cífková R, Bruthans J, Wohlfahrt P, et al. 30-year trends in major cardiovascular risk factors in the Czech population, Czech MONICA and Czech post-MONICA, 1985-2016/17. PLoS One. 2020;15(5):e0232845. Available from: . Go to original source...
    3. Taniwall A, Lustigova M, Broz J, et al. Arterial hypertension in the Czech Republic: prevalence, awareness, and control among adults aged 25-64 in 2019: a cross-sectional study. Eur Heart J. 2023;44(Suppl 2):ehad655.2319. Go to original source...
    4. McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912-4018. Go to original source... Go to PubMed...
    5. Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension. J Hypertens. 2023;41(12):1874-2071. Available from: . Go to original source...
    6. Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025;82(10):e212-e316. doi:10.1161/HYP.0000000000000249. Go to original source... Go to PubMed...
    7. Mancia G, Rea F, Corrao G, et al. Two-drug combinations as first-step antihypertensive treatment. Circ Res. 2019;124(7):1113-1123. Go to original source...
    8. Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11 000 participants from 42 trials. Am J Med. 2009;122(3):290-300. Go to original source... Go to PubMed...
    9. MacDonald TM, Williams B, Webb DJ, et al. Combination therapy is superior to sequential monotherapy for the initial treatment of hypertension: a double-blind randomized controlled trial. J Am Heart Assoc. 2017;6(11):e006986. Available from: . Go to original source... Go to PubMed...
    10. Egan BM, Bandyopadhyay D, Shaftman SR, et al. Initial monotherapy and combination therapy and hypertension control the first year. Hypertension. 2012;59(6):1124-1131. Go to original source... Go to PubMed...
    11. Rea F, Corrao G, Merlino L, et al. Initial antihypertensive treatment strategies and therapeutic inertia. Hypertension. 2018;72(4):846-853. Go to original source...
    12. Gupta AK, Arshad S, Poulter NR. Compliance, safety, and effectiveness of fixed-dose combinations of antihypertensive agents: a meta-analysis. Hypertension. 2010;55(2):399-407. Go to original source... Go to PubMed...
    13. Parati G, Kjeldsen S, Coca A, et al. Adherence to single-pill versus free-equivalent combination therapy in hypertension: a systematic review and meta-analysis. Hypertension. 2021;77(3):692-705. Go to original source... Go to PubMed...
    14. Liakos CI, Papadopoulos DP, Kotsis VT. Adherence to treatment, safety, tolerance, and effectiveness of perindopril/amlodipine fixed-dose combination in Greek patients with hypertension and stable coronary artery disease: a Pan-Hellenic prospective observational study of daily clinical practice. Am J Cardiovasc Drugs. 2017;17(5):391-398. Available from: . Go to original source...
    15. Dahlöf B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366(9489):895-906. Available from: . Go to original source... Go to PubMed...
    16. Patel A, MacMahon S, Chalmers J, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (ADVANCE): a randomised controlled trial. Lancet. 2007;370(9590):829-840. Available from: . Go to original source...

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