*These first two authors contributed equally to this work.
We compared the efficacy and safety of valsartan and rosuvastatin combination therapy with each treatment alone in hypercholesterolemic hypertensive patients.
Patients who met inclusion criteria were randomized to receive 1 of the following 2-month drug regimens: valsartan 160 mg plus rosuvastatin 20 mg, valsartan 160 mg plus placebo, or rosuvastatin 20 mg plus placebo. The primary efficacy variables were change in sitting diastolic blood pressure (sitDBP) and sitting systolic blood pressure (sitSBP), and percentage change in low-density lipoprotein-cholesterol (LDL-C) in the combination, valsartan, and rosuvastatin groups. Adverse events (AEs) during the study were analyzed.
A total of 354 patients were screened and 123 of them were finally randomized. Changes of sitDBP by least squares mean (LSM) were -11.1, -7.2, and -3.6 mm Hg, respectively, and was greater in the combination, as compared to both valsartan (p=0.02) and rosuvastatin (p<0.001). Changes of sitSBP by LSM were -13.2, -10.8, and -4.9 mm Hg, and was greater in the combination, as compared to rosuvastatin (p=0.006) and not valsartan (p=0.42). Percentage changes of LDL-C by LSM were -52, -4, and -47% in each group, and was greater in the combination, as compared to valsartan (p<0.001), similar to rosuvastatin (p=0.16). Most AEs were mild and resolved by the end of the study.
Combination treatment with valsartan and rosuvastatin exhibited an additive blood pressure-lowering effect with acceptable tolerability, as compared to valsartan monotherapy. Its lipid lowering effect was similar to rosuvatatin monotherapy.
Hypertension and hyperlipidemia are well known cardiovascular risk factors that commonly coexist in a single patient.
Valsartan, an ARB, has dose-dependent efficacy for lowering BP.
We investigated whether the combination of valsartan and rosuvastatin would show additional efficacy and acceptable safety, as compared to each component alone for patients with hypertension and hyperlipidemia.
Patients aged 20-80 years who had hypertension and hyperlipidemia were eligible for the study. At screening, patients who had been administered antihypertensive agents, or drug-naïve patients with sitting diastolic blood pressure (sitDBP) ≥90 mm Hg were included. Patients who had coronary artery disease (CAD) or CAD equivalents, and were classified as high risk according to National Cholesterol Education Program- Adult Treatment Panel (NCEP-ATP) III guidelines,
Exclusion criteria included sitting systolic blood pressure (sitSBP)≥180 mm Hg or sitDBP≥110 mm Hg (for the high risk group, sitSBP≥160 mm Hg or sitDBP≥100 mm Hg), LDL-C≥250 mg/dL, or TG≥400 mg/dL at screening and randomization (week 0); symptomatic orthostatic hypotension at screening (decrease in sitSBP≥20 mm Hg or decrease in sitDBP≥10 mm Hg); history of acute coronary syndrome within 6 months, percutaneous coronary intervention or coronary artery bypass graft, severe heart failure (functional class III or IV), severe valve disease, clinically significant arrhythmias; or stroke or transient ischemic attack within the last 6 months. Patients with severe obesity (body mass index≥40 kg/m2); uncontrolled diabetes mellitus (Hemoglobin A1c≥9.0%); thyroid dysfunction (TSH≥1.5xupper limit of normal [ULN]); creatine kinase (CK) >2×ULN; creatinine clearance <30 mL/min; serum creatinine ≥2 mg/dL; alanine transaminase (ALT) or aspartate aminotransferase (AST) ≥2×ULN; potassium <3.5 mEq/L or >5.5 mEq/L were also excluded.
This study was a multicenter, randomized, factorial, double-blind, double-dummy Phase III trial to evaluate the efficacy and safety of combination treatment with valsartan 160 mg and rosuvastatin 20 mg, as compared to each component alone in patients with hypertension and hyperlipidemia. The protocol was approved by the local Institutional Review Boards, and all subjects gave written informed consent at enrollment. The study was conducted in accordance with Korean Good Clinical Practice guidelines and the Declaration of Helsinki. This study was started on May 8th 2012 and finished on March 29th 2013.
Screening was conducted for patients who satisfied inclusion/exclusion criteria. Subjects who were taking antihypertensive or lipid-modifying agents discontinued those medications. Subjects who passed the screening tests underwent 6-week-TLC. After eligibility based on BP and lipid levels (week 0) was ascertained, subjects were randomly assigned to 1 of 3 treatment groups: combination therapy (valsartan 160 mg+rosuvastatin 20 mg), valsartan (valsartan 160 mg+placebo), or rosuvastatin (rosuvastatin 20 mg+placebo). Placebo was administrated during the treatment period to maintain double blindness. Randomization was performed by randomization tables prepared for each institution. After randomization, a code was transferred to a code manager who maintains the code in a separate file and breaks it in an emergency. However, no breaking of the code occurred in this study.
Subjects visited at the beginning of the 0th, 4th, and 8th weeks during the 8-week treatment period. Efficacy and safety were assessed at weeks 4 and 8. BP was measured by the same person at a regular time with a validated electronic sphygmomanometer (HEM-7080 IT, Omron Healthcare, Kyoto, Japan). Twelve hour (for patients without diabetes) or 8 hour (for patients with diabetes) fasting blood samples for lipid profile obtained during regular visits were analyzed in the central laboratory. Double blind protocol was maintained during the treatment period.
Major safety considerations leading to study treatment discontinuation were: uncontrolled high BP (e.g., sitSBP≥200 mm Hg, sitDBP≥120 mm Hg) or hypotension (e.g., sitSBP <90 mm Hg, sitDBP <60 mm Hg); ALT and AST >3×ULN; CK >5×ULN at any time during the study period.
Primary efficacy variables were change in sitDBP and sitSBP at week 8 for the combination and valsartan alone groups, and percentage change in LDL-C at week 8 for the combination and rosuvastatin alone groups. In addition, we analyzed changes of pulse pressure in each group. Secondary efficacy variables were proportion of subjects achieving BP treatment target at weeks 4 and 8 according to the European Society of Hypertension and European Society of Cardiology hypertension guideline (2003)
Safety was based on the number of patients experiencing any adverse event (AE), or serious AE.
A serious AE refers to an AE that causes death or threatens life; causes short- or long-term hospitalization; causes permanent disability or reduction in function; causes congenital abnormality or a birth defect; or causes other medically important events. AEs and serious AEs were recorded at each study visit by history taking, physical examinations, and laboratory tests. The relationship of AEs to investigational products was evaluated.
The superiority of the combination therapy compared to each mono-therapy regarding changes of BP and LDL-C (change of sitDBP in the combination group vs. the rosuvastatin group and the % change of LDL-C in the combination group vs. the valsartan group) was tested in this study. For sample size calculation, 95% power was selected to each efficacy variable. Because two primary evaluation points needed to be proved at once, overall power became 90.25% (0.95×0.95=0.9025). Thirty-three patients per treatment group were needed to provide 95% power at a 2.5% confidence level (2-tailed). Differences in sitDBP and LDL-C changes were based on prior studies that used valsartan and rosuvastatin and assumed as -6.9 mm Hg
Continuous variables were presented as mean and standard deviation. Frequency and percentage were presented for categorical variables. A test was conducted to determine any difference in baseline data between treatment groups. Analysis of variance or Kruskal-Wallis tests were conducted for continuous variables. Chisquare or Fisher's exact tests were conducted for categorical variables. The paired t-test was used to assess the difference in parameter before and after drug treatment within each group. Student's t-test was used to compare the mean value of continuous outcome variables between 2 groups. Analysis of covariance (ANCOVA) was conducted for the analysis of primary efficacy variables, with baseline levels as covariate. Outcome variables in the combination group were compared to those from the monotherapy group with the least squares mean estimated by ANCOVA for sitDBP change, sitSBP change, and LDL-C percentage change. A 2-tailed 95% confidence interval was calculated for the outcome variables. Prior to the ANCOVA, a test was performed for any interaction between the covariate and the treatment groups. If a significant interaction was present (p value<0.1), the corresponding covariate was excluded from the final ANCOVA model. All analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA).
A total of 354 subjects from 23 institutions underwent screening, of whom 123 were randomized. 231 subjects were excluded after TLC. The number of exclusion before randomization was relatively large and mainly due to improvement of LDL-C or BP after 6-week TLC. One hundred and six and 74 subjects did not meet LDL-C level and BP, respectively. Thirty-four subjects declined to participate after submission of written consent. Of the randomized subjects, 101 completed the study: 35 in the combination group, 36 in the valsartan group, and 30 in the rosuvastatin group. Of the 123 randomized subjects, 121 were included in the safety set, while 116 were included in the analysis set (
Characteristics of the subjects who were randomized were presented in
Changes in outcome variables at week 8 were presented in
Percentage changes of LDL-C were -53±12% in the combination group and -46±16% in the rosuvastatin group. The difference between the 2 groups was not significant before and after ANCOVA adjustment (Fig. 2B). In the valsartan group, LDL-C levels did not significantly change through the 8-week treatment (-4±19%, p=0.065) (
Proportion of subjects who achieved target BP at weeks 4 and 8 were shown in
Proportion of subjects who achieved target LDL-C level at weeks 4 and 8 were presented in
Ten (23%) in the combination group, 7 (17%) in the valsartan group, and 4 (11%) in the rosuvastatin group experienced AEs. Most AEs were mild and resolved at the end of the study (
One serious AE was a patient admitted on a day of randomization due to nausea and poor oral intake. However, this symptom was not likely to be associated with the test agents. In addition, they were both resolved after occurrence.
Combination of valsartan 160 mg and rosuvastatin 20 mg reduced sitDBP more than valsartan 160 mg alone by week 8 of treatment. sitSBP reduction was not significantly different between the 2 groups. Percentage change of LDL-C was similar between the combination and rosuvastatin groups. Target BP and LDL-C achievement rates were higher in the combination group than each group alone without statistical significance. Treatment regimens were well-tolerated during the study. These results demonstrated that this combination has an additive effect on BP lowering and is an appropriate therapeutic option for patients with hypertension and hyperlipidemia.
Several reports demonstrated effects of statin on BP in animal studies. Lovastatin and pravastatin attenuated the onset and progression of hypertension and reduced proteinuria and glomerular injury.
Sposito et al.
In addition, the difference in target BP achievement rate between the 2 groups was not statistically significant. However, we cannot rule out a statistically greater BP lowering in the combination group with a study of a larger sample size.
The mechanism by which statins affect blood pressure is not clearly understood. One possibility is that statins' antihypertensive effect is dependent on their ability to prevent renal vascular hypertrophy. Another explanation is that statins improve endothelium dependent vaso-relaxation,
To the best our knowledge, this randomized, double-blind study is the first to show the additive effect of valsartan and rosuvastatin combination therapy on BP. Because these 2 agents are now popularly prescribed based on clinical evidence, our data further supports that this combination is a reasonable regimen. However, this study had a relatively small sample size and was conducted over a short period of time. Thus, further clinical studies over a longer period are needed to confirm this combination's clinical benefit. It was beyond the scope of the current study to explore potential mechanisms of the 2 agents' additive effect. Further studies on the biological mechanisms, such as vascular function, might be helpful in understanding our results. The randomization process was strictly conducted in our study with the support of a statistics specialist. However, marginal imbalance in the baseline characteristics seemed to occur by chance. Imbalance in the baseline characteristics is known to occur even in qualified randomized trials. Moreover, such imbalance reportedly does not affect the internal validity of studies.
This study found greater BP reduction in combination of valsartan 160 mg and rosuvastatin 20 mg than valsartan 160 mg, and comparable LDL-C lowering to rosuvastatin 20 mg. This result indicated that a combination of these 2 agents might be a reasonable therapeutic option for patients with hypertension and hyperlipidemia.
This study was supported by LG Life Science. The sponsor provided investigational products including the active and placebo pills used in this study. J.H.J and Y.L.J are full-time employees of LG Life. Yangsoo Jang and Sang-Hak Lee contributed to the study design, interpretation of the data, and writing of the manuscript. Jae-Hyeon Juhn and YeiLe Jung contributed to the statistical analyses. Ji-Yong Jang contributed to the interpretation of the data and writing of the manuscript. All authors contributed to the design of the article and revised the manuscript. We thank all study participants, investigators, and coordinators.
The online-only Data Supplement is available with this article at
Changes of pulse pressure and fasting glucose level at week 8
Combination (n=43) | Valsartan (n=41) | Rosuvastatin (n=39) | p | |
---|---|---|---|---|
Age, years | 61.3±8.5 | 62.6±8.2 | 60.2±11.1 | 0.59 |
Male | 27 (63) | 27 (66) | 31 (80) | 0.23 |
Medical history | ||||
Diabetes mellitus | 5 (12) | 7 (17) | 8 (21) | 0.54 |
Hypertension | 37 (86) | 39 (95) | 34 (87) | 0.35 |
Hyperlipidemia | 36 (84) | 33 (81) | 31 (80) | 0.87 |
Coronary artery disease | 2 (5) | 0 (0) | 0 (0) | 0.33 |
Body mass index, kg/m2 | 25.2±2.4 | 25.5±3.4 | 25.5±3.1 | 0.93 |
sitDBP, mm Hg | 94±6 | 93±5 | 94±6 | 0.97 |
sitSBP, mm Hg | 147±11 | 153±11 | 150±12 | 0.055 |
Pulse pressure, mm Hg | 53.5±11.3 | 60±11.8 | 56.4±11 | 0.04 |
Fasting glucose, mg/dL | 109±26 | 103±12 | 111±24 | 0.38 |
BUN, mg/dL | 14.8±4.5 | 16.5±4.3 | 15.7±4.2 | 0.20 |
Creatinine, mg/dL | 0.9±0.2 | 0.9±0.2 | 0.9±0.2 | 0.56 |
eGFR, mL/min/1.73 m2 | 81.9±20.3 | 85.7±20.7 | 83.1±18.2 | 0.77 |
Lipid profile | ||||
Total cholesterol, mg/dL | 239±36 | 230±35 | 226±32 | 0.20 |
TG, mg/dL | 186±76 | 155±64 | 186±120 | 0.24 |
HDL-C, mg/dL | 48±9 | 49±10 | 49±11 | 0.83 |
LDL-C, mg/dL | 156±30 | 154±29 | 144±25 | 0.16 |
Values are mean±SD or number (%).; sitDBP: sitting diastolic blood pressure. sitSBP: sitting systolic blood pressure, BUN: blood urea nitrogen, eGFR: estimate glomerular filtration rate, TG: triglyceride, HDL-C: high-density lipoprotein-cholesterol, LDL-C: low-density lipoprotein-cholesterol
Combination (n=41) | Valsartan (n=40) | Rosuvastatin (n=35) | p* | p† | |
---|---|---|---|---|---|
sitDBP, mm Hg | |||||
Before | 94±7 | 93±5 | 94±6 | ||
After | 83±10 | 86±8 | 90±8 | ||
Change | -11.2±7.1 | -7.2±7.2 | -3.6±6.5 | ||
Change (LSM) | -11.1 | -7.2 | -3.6 | 0.02 | <0.001 |
p‡ | <0.001 | <0.001 | 0.002 | ||
sitSBP, mm Hg | |||||
Before | 146±11 | 153±11 | 150±12 | ||
After | 134±15 | 141±15 | 145±15 | ||
Change | -12.5±11.2 | -11.6±14.4 | -5.2±13.2 | ||
Change (LSM) | -13.2 | -10.8 | -4.9 | 0.42 | 0.006 |
p‡ | <0.001 | <0.001 | 0.025 | ||
LDL-C, mg/dL | |||||
Before | 158±28 | 155±29 | 145±24 | ||
After | 74±19 | 146±28 | 77±22 | ||
% change | -53±12 | -4±19 | -46±16 | ||
% change (LSM) | -52 | -4 | -47 | <0.001 | 0.16 |
p‡ | <0.001 | 0.065 | <0.001 |
Values are mean±SD. *Comparison between combination vs. valsartan groups, †Comparison between combination vs. rosuvastatin groups, ‡Comparison in a group before and after treatment. LDL-C: low-density lipoprotein-cholesterol, sitDBP: sitting diastolic blood pressure, LSM: least squares mean, sitSBP: sitting systolic blood pressure
Combination (n=43) | Valsartan (n=41) | Rosuvastatin (n=37) | p | |
---|---|---|---|---|
Any adverse events | 15 | 11 | 7 | |
Number of subjects who experienced AEs | 10 (23.3 ) | 7 (17.1 ) | 4 (10.8 ) | 0.34 |
Number of subjects who experienced SAEs | 1 (2.3 ) | 0 (0 ) | 0 (0 ) | 1.00 |
AE: adverse event, SAE: serious adverse event