In everyday medical practice, physicians often need to manage patients whose blood pressure is not well controlled. Those with a history of cerebrovascular disease are a high-risk group in need of rapid blood pressure control.
The PICASSO study was a real-life, observational trial involving 9257 inadequately treated hypertensive patients who were switched from previous therapy to the fixed-dose combination of perindopril 10 mg/indapamide 2.5 mg (PI) for 3 months. A subanalysis of data of 1117 hypertensive patients who met the clinical criteria of previous stroke or transient ischemic attack was performed. Twenty-four hour ambulatory blood pressure measurements (ABPMs) were also done in a small group of patients (n:38).
At baseline, mean systolic/diastolic blood pressure (SBP/DBP) was 161.5 ± 15.2/93.1 ± 9.9 mmHg. After 1 month with the fixed dose of PI, average office SBP/DBP decreased to 140.0 ± 11.9/83.5 ± 7.7 mmHg. After 3 months, SBP/DBP had dropped to 132.9 ± 9.8/80.0 ± 6.2 mmHg, by 28.6 ± 15.5/13.1 ± 10.0 mmHg (p < 0.001). Blood pressure control rate (< 140/90 mmHg) was 67.3% after 3 months. When data were stratified by baseline blood pressure, decreases in SBP/DBP were statistically significant in patients with all grades (1–3) of hypertension. In patients previously treated with an angiotensin-converting enzyme inhibitor ± hydrochlorothiazide (n = 677), blood pressure decreased by 29.8 ± 15.5/13.3 ± 10.2 mmHg (p < 0.001). Decreases in 24-h ABPM values were also significant (n = 38). Treatment was well tolerated; only a few adverse events were recorded.
This study suggests that fixed combination perindopril 10 mg/indapamide 2.5 mg is an effective and well-tolerated treatment for patients with a history of stroke or transient ischemic attack.
EGIS Pharmaceuticals Plc.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Zhang H, Thijs L, Staessen JA. Blood pressure lowering for primary and secondary prevention of stroke. Hypertension. 2006;48:187–95.
World Health Organisation. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: Switzerland WHO Press; World Health Organization; 2009.
Ohkubo T, Asayama K, Kikuya M, et al. Prediction of ischaemic and haemorrhagic stroke by self-measured blood pressure at home: the Ohasama study. Blood Press Monit. 2004;9(6):315–20.
Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–13.
Peters R, Beckett N, McCormack T, et al. Treating hypertension in the very elderly-benefits, risks, and future directions, a focus on the hypertension in the very elderly trial. Eur Heart J. 2014;35:1712–8.
Dhamoon MS, Sciacca RR, Rundek T, et al. Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study. Neurology. 2006;66:641–6.
Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31:1281–357.
Mourad JJ, Waeber B, Zannad F, et al. Comparison of different therapeutic strategies in hypertension: a low-dose combination of perindopril/indapamide versus a sequential monotherapy or a stepped-care approach. J Hypertens. 2004;22:2379–86.
Mallion JM, Chamontin B, Asmar R, et al. Twenty-four-hour ambulatory blood pressure monitoring efficacy of perindopril/indapamide first-line combination in hypertensive patients: the REASON study. Am J Hypertens. 2004;17:245–51.
PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358(9287):1033–41.
Mogensen CE, Viberti G, Halimi S, et al. Effect of low-dose perindopril/indapamide on albuminuria in diabetes: preterax in albuminuria regression: PREMIER. Hypertension. 2003;41:1063–71.
Dahlöf B, Gosse P, Gueret P, et al. Perindopril/indapamide combination more effective than enalapril in reducing blood pressure and left ventricular mass: the PICXEL study. J Hypertens. 2005;23:2063–70.
Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–98.
Farsang C, Picasso Investigators. Blood pressure and metabolic efficacy of fixed-dose combination of perindopril and indapamide in everyday practice. Blood Press. 2013;22(Suppl 1):3–10.
Farsang C. Efficacy and tolerability of fixed-dose combination of perindopril/indapamide in type 2 diabetes mellitus: PICASSO trial. Adv Ther. 2014;31(3):333–44.
Coverex-AS Komb Forte. Summary of product characteristics. Budapest: EGIS Pharmaceuticals Plc; 2009.
PATS Collaborating Group. Post-stroke antihypertensive treatment study. A preliminary result. Chin Med J (Engl). 1995;108(9):710–7.
Arima H, Chalmers J, Woodward M, et al. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens. 2006;24:1201–8.
Walters M, Muir S, Shah I, et al. Effect of perindopril on cerebral vasomotor reactivity in patients with lacunar infarction. Stroke. 2004;35:1899–902.
Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160–236.
Liu Lisheng, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res. 2009;32:1032–40.
National Clinical Guideline Centre (UK). Hypertension: Clinical management of primary hypertension in adults (NICE clinical guideline 127). London. 2011.
Kuo SW, Pei D, Hung YJ, et al. Effect of indapamide SR in the treatment of hypertensive patients with type 2 diabetes. Am J Hypertens. 2003;16:623–8.
Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev. 2004;3:CD003974 (Review. Update in: Cochrane Database Syst Rev. 2010;(1):CD003974).
The authors acknowledge the contribution of all members of the PICASSO investigator group and would like to acknowledge the assistance of Bela Malomvölgyi, MD (medical advisor), and Norbert Habony, MD (coordinator).
PICASSO study was funded by EGIS Pharmaceuticals Plc. (Budapest, Hungary). The article processing charges were funded by Szívkatéterezés Győr Alapítvány. All authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and accuracy of the data analysis.
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Csaba András Dézsi and Csaba Farsang have nothing to disclose.
Compliance with Ethics Guidelines
All patients signed informed consent prior to enrollment in the study. The Ethics Committee of the Hungarian Medical Research Council (TUKEB no. 8-34812009-1018EKU (866/PII09.) approved the protocol. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.
The data sets during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Enhanced digital features
To view enhanced digital features for this article go to https://doi.org/10.6084/m9.figshare.6148337.
Rights and permissions
About this article
Cite this article
Dézsi, C.A., Farsang, C. & on behalf of The PICASSO Investigators. Efficacy and Tolerability of Fixed-Dose Combination Perindopril/Indapamide in Hypertensive Patients with a History of Stroke or Transient Ischemic Attack: PICASSO Trial. Adv Ther 35, 644–654 (2018). https://doi.org/10.1007/s12325-018-0705-1
- Ambulatory blood pressure monitoring
- Combination treatment