Optimal Antihypertensive Medication Regimen for Patients with Hypertension Urgency, HFrEF, and CAD
First-Line Medications to Add
- The American Heart Association recommends adding an ACE inhibitor (or ARB) as first-line therapy to improve outcomes in patients with HFrEF and effectively lower blood pressure 1, 2, 3
- The American College of Cardiology suggests using evidence-based beta-blockers for HFrEF, such as carvedilol, metoprolol succinate, bisoprolol, or nebivolol, which have demonstrated mortality benefit in HFrEF while also providing blood pressure control 1, 2, 3
- An aldosterone receptor antagonist should be included if the patient has NYHA class II-IV HF with ejection fraction <40%, with options including spironolactone or eplerenone, and monitoring serum potassium closely 1, 3
Diuretic Therapy
- The American Heart Association recommends using thiazide or thiazide-type diuretics for BP control and to manage volume overload, in conjunction with an ACE inhibitor/ARB and beta-blocker 1, 3
Additional Considerations
- The European Society of Cardiology suggests considering sacubitril/valsartan as a replacement for ACE inhibitor if the patient remains symptomatic despite optimal treatment with an ACE inhibitor, beta-blocker, and aldosterone receptor antagonist 4
- Hydralazine plus isosorbide dinitrate should be added to the regimen if the patient is African American with NYHA class III or IV HFrEF 1, 3
Medications to Avoid
- The American College of Cardiology recommends avoiding non-dihydropyridine calcium channel blockers, such as verapamil and diltiazem, due to their negative inotropic effects and risk of worsening HF 1, 4
- Alpha-blockers, such as doxazosin, should only be used if other agents are inadequate to achieve BP control 1
Blood Pressure Targets
- The American Heart Association recommends a target BP of <140/90 mmHg, with consideration for <130/80 mmHg if tolerated, and monitoring for orthostatic changes, especially in elderly patients 1