Too much, too soon? The argument against initial combination therapy in stage I hypertension

As the leading modifiable risk factor for global cardiovascular disease, hypertension management is among the most important tasks for clinicians worldwide [ 1 ]. Unfortunately, despite significant advances in our understanding of improved treatment thresholds, identification of secondary causes, and development of new pharmacotherapies, control of hypertension has stagnated and even reversed in the last 10 years, highlighting the need for novel therapeutic approaches [ 2 , 3 ]. Single pill combinations (SPCs), which combine multiple blood pressure medications into a single pill, have emerged as a promising intervention to improve blood pressure control in appropriately selected patients. In recent years, the use of SPCs in patients with Stage II hypertension, defined as systolic blood pressure (SBP) > 140 mmHg and/or diastolic blood pressure (DBP) > 90 mmHg, has shown promise, with trials demonstrating significant reductions in blood pressure and higher proportions of patients reaching control [ 4 , 5 , 6 ]. However, we must be wary of extrapolating such results to all patients with Stage I hypertension, as doing so may be premature at best, and at worst a step backward in the global fight against hypertension.