Over the past 2 years, considerable excitement has been building over the results of the ACCOMPLISH study. This trial suggested that the combination of benazapril plus amlodipine is superior to benazapril plus hydrochlorothiazide for the prevention of a composite cardiovascular outcome. While there are methodological concerns regarding this trial that make me question its generalizability, it is thought-provoking to consider that one medication combination is superior to another even if blood-pressure between the 2 groups is negligible.
In the latest issue of Lancet, a follow-up paper suggests that benzapril-amlodipine prevented renal outcomes more-so than in the benazapril-hydrochlorothiazide arm. However, as the excellent accompanying editorial points out, all is not as it appears. (continued...)
This trial considered both doubling of creatinine and end-stage renal disease (ESRD) as its combined renal end-point. However, only the doubling outcome was better in the amlodipine arm while the rates of ESRD were the same between the 2 groups. This finding suggests that the hemodynamic effect of the diuretic may lead to increased creatinine on a hemodynamic basis but that does not translate to permanent renal injury or ESRD.
This shortcoming of the ACCOMPLISH trial should be given serious consideration before this medication combination is recommended over another, especially when they both lower blood pressure equally well.