Initial combination treatment in the 2018 ESC/ESH hypertension guidelines

The most important novelty of the 2018 Hypertension Guidelines of the European Society of Cardiology and the European Society of Hypertension (ESC/ESH) (1) is the decision to abandon the step-care treatment approach, i.e., initial monotherapy followed by the sequential addition of one, two, or more antihypertensive agents, as the most important treatment strategy to lower elevated blood pressure (BP) and achieve BP control. The guidelines now recommend two antihypertensive drugs as the most important initial treatment strategy, moving to a threedrug combination and then to the addition of more drugs if BP reduction is still insufficient and BP target is not achieved. The reason for abandoning monotherapy as the most common firststep treatment is that evidence indicates that initial monotherapy maximizes two major barriers to BP control, i.e., low adherence to the prescribed treatment regimen (1) and the so-called therapeutic inertia (1). Low adherence to treatment prevents persistent BP control and markedly increases the risk of death and hospitalization due to cardiovascular events (2). Therapeutic inertia maintains patients in monotherapy even when BP is not controlled and addition of other drugs is necessary (3), which substantially contributes to the low number of hypertensive patients in whom treatment achieves the recommended BP target (4). This goal that requires concomitant administration of two or more antihypertensive drugs (5) with different (and complementary) mechanisms of action in most patients (> 80%) because BP is a multiregulated variable, whereas hypertension depends on several causative factors and mechanisms.