Blood Pressure Management in Heart Failure

Primary Recommendation: ACE Inhibitors

The European Society of Cardiology recommends ACE inhibitors as the first-line blood pressure medication for patients with heart failure, as they reduce mortality, hospitalizations, and improve quality of life 1, 2
ACE inhibitors should be initiated in all patients with heart failure unless contraindicated, providing a robust mortality benefit among blood pressure medications, with evidence demonstrating 13 deaths prevented per 1000 patient-years of treatment and 99 hospital admissions reduced per 1000 patient-years 1
The American Heart Association suggests that ACE inhibitors prevent 13 deaths per 1000 patient-years and reduce hospital admissions by 99 per 1000 patient-years, with the most benefit seen in patients with reduced ejection fraction 1

The European Society of Cardiology recommends ARBs as an alternative to ACE inhibitors in patients who cannot tolerate them due to cough or other side effects, with similar benefits to ACE inhibitors in heart failure patients 2, 3, 6
ARBs are specifically indicated when ACE inhibitor-induced cough is severe, or other ACE inhibitor side effects are intolerable, with losartan being a suitable substitute 2, 3

The American College of Cardiology recommends beta-blockers as a companion therapy to ACE inhibitors, with only three beta-blockers (bisoprolol, carvedilol, and metoprolol succinate extended-release) proven to reduce mortality in heart failure patients 1, 2, 4, 5
Beta-blockers prevent 38 deaths per 1000 patient-years and reduce hospitalizations by 65 per 1000 patient-years, with a mortality benefit equal to or greater than ACE inhibitors 1, 2, 5

The European Society of Cardiology recommends mineralocorticoid receptor antagonists (MRAs) as an additional therapy for patients with NYHA class III-IV heart failure, with spironolactone preventing 57 deaths per 1000 patient-years and reducing hospitalizations by 138 per 1000 patient-years 1, 2, 4, 6

The European Society of Cardiology advises seeking specialist advice before starting ACE inhibitors in patients with significant renal dysfunction, hyperkalemia, or symptomatic hypotension 1, 2, 3, 4, 6, 7
Asymptomatic low blood pressure requires no change in therapy, while symptomatic hypotension requires reconsideration of nitrates, calcium channel blockers, and other vasodilators, and potentially reducing diuretic dose or seeking specialist advice 1, 2, 5, 6