OBJECTIVES: To analyze the risk and costs of the first hypertension-associated event, compliance and persistence in naïve hypertensive patients after initiating monotherapy with any of the first-line antihypertensive drug classes in Germany. METHODS: A retrospective cohort study in the IMS Disease Analyzer database was performed. Study subjects included all previously untreated hypertensive adults who were free from hypertension-associated comorbidities and were prescribed initial monotherapy with angiotensin II receptor blockers (ARBs), ACE-inhibitors (ACEIs), beta-blockers (BBs), calcium channel blockers (CCBs) or diuretics. Compliance and persistence were determined for each drug class separately and for the group of non-ARBs (pooled data) within two years. The risk of the first hypertension-associated event (cardiovascular complications, new onset diabetes) was analyzed using a Cox regression model adjusted for sociodemographic variables, compliance and persistence. Based on these results average costs per event were estimated from the German statutory health insurance perspective.RESULTS: A total of 7661 patients were identified with a follow-up of at least 2 years. Mean follow-up was 5.6 to 6.3 years. Compliance (0.86 vs. 0.82 and 0.74, respectively) and persistence (509 days vs. 459 and 324 days) was better with ARBs (all p <0.05) than with the group of non-ARBs and diuretics, respectively. The risk of the first hypertension-associated event was higher (all p <0.05) with diuretics (adjusted hazard ratio (aHR) 0.68), BBs (0.79), CCBs (0.78), and the group of non-ARBs (0.81) and was similar with ACEIs (aHR 0.93, p = 0.37) compared to ARBs. Similar findings were found for cardiovascular complication rates. The estimated average costs per event for the first event were lower with ARBs (€2339.95) than with the other drug classes (€2531.68 – €3910.47).CONCLUSIONS: Our real-world data indicate that initiating monotherapy with ARB shows significant benefits in most outcomes including hypertension-related complications compared to other antihypertensive drug monotherapies.