Management of Blood Pressure in Patients with Coronary Artery Disease

Preferred Antihypertensive Medications

The American Heart Association recommends beta-blockers as the drugs of first choice for treatment of hypertension in patients with CAD, particularly those with angina, as they alleviate ischemia and angina through negative inotropic and chronotropic actions 1, 2
The American Heart Association recommends ACE inhibitors or ARBs in combination with beta-blockers, especially in patients with diabetes mellitus and/or left ventricular systolic dysfunction 3, 4
The American Heart Association recommends thiazide diuretics as part of the antihypertensive regimen in patients with CAD 4
If beta-blockers are contraindicated or produce intolerable side effects, a non-dihydropyridine calcium channel blocker (such as diltiazem or verapamil) can be substituted, but not if there is left ventricular dysfunction 4

The American Heart Association recommends a target blood pressure of <130/80 mmHg for patients with established CAD 5, 6
In patients with left ventricular dysfunction, consideration should be given to lowering BP even further, to <120/80 mmHg 4
Caution is advised when lowering diastolic blood pressure below 60 mmHg, especially in patients over 60 years of age or with diabetes mellitus, due to potential risk of coronary hypoperfusion 2

Hydralazine is not listed as a preferred agent for blood pressure management in patients with CAD in current guidelines from the American Heart Association 1, 2, 5
Hydralazine may be considered as an add-on therapy when blood pressure remains uncontrolled despite optimal doses of first-line agents, according to the American Society of Hypertension 7
When used in patients with CAD, hydralazine should be started with low doses and titrated slowly, and patients should be monitored closely for signs of myocardial ischemia 7

Most hypertensive patients with CAD will require 2 or more antihypertensive medications to achieve their BP goals, according to the American Heart Association 1, 7
When BP is more than 20 mmHg above systolic goal or 10 mmHg above diastolic goal, consideration should be given to initiating therapy with 2 drugs, as recommended by the American Society of Hypertension 7
In patients with elevated diastolic blood pressure and CAD with evidence of myocardial ischemia, BP should be lowered slowly, as recommended by the American Heart Association 2
The combination of a beta-blocker and either of the non-dihydropyridine CCBs (diltiazem or verapamil) should be used with caution due to increased risk of bradyarrhythmias and heart failure, according to the American Heart Association 4