Management of Hypertension

Patient Assessment and Monitoring

• The American College of Cardiology recommends ensuring systolic blood pressure is greater than 100 mmHg before initiation of antihypertensive therapy, and monitoring for symptomatic hypotension, such as dizziness and lightheadedness, with a strength of evidence based on clinical trials 1
• Patients with diabetes require continued periodic monitoring of serum potassium levels, especially when using concomitant medications that can increase potassium, as recommended by the American Heart Association 2
• Blood pressure, renal function, and potassium levels should be checked within 1-2 weeks after starting or increasing the dose of antihypertensive medications, with more frequent monitoring needed in patients with a history of renal impairment, elderly patients (≥75 years), or concomitant use of other medications affecting renal function 1

Dose Adjustment and Management

• The American College of Cardiology suggests considering reducing diuretic dose in non-congested patients to mitigate hypotensive effects, and reducing diuretic dose first in non-congested patients in case of premature discontinuation due to mild hypotension 1
• Up to 25% of patients may develop hypotension when treated with certain medications, highlighting the importance of ensuring patients are not volume-depleted before initiation, as recommended by the American College of Cardiology 1
• When transitioning between antihypertensive medications, the following guidelines apply:

• The initial dose of sacubitril/valsartan (Entresto) should be selected based on the patient's current losartan dose:

  Losartan Dose	Entresto Initial Dose
  High-dose (100 mg daily)	49/51 mg twice daily
  Low/medium-dose (25-50 mg daily)	24/26 mg twice daily

  1

• Standard starting dose of sacubitril/valsartan is 49/51 mg twice daily, with a target dose of 97/103 mg twice daily after 2-4 weeks of titration 1, 5
• Reduced starting dose of 24/26 mg twice daily is recommended for certain patient populations, such as those with severe renal impairment, moderate hepatic impairment, symptomatic hypotension, or systolic blood pressure <100 mmHg 1, 5
• Contraindications to sacubitril/valsartan include:
• Dose adjustments are needed for patients with:
• Sacubitril/valsartan should be held in patients with:
• When restarting sacubitril/valsartan after holding, consider starting at a lower dose (24/26 mg twice daily) and titrating the dose gradually every 2-4 weeks as tolerated to target dose of 97/103 mg twice daily 1, 5
• The American College of Cardiology advises ensuring patients are not volume-depleted before initiating or continuing sacubitril/valsartan during hospitalization for heart failure, and recommends maintaining patients on sacubitril/valsartan therapy when possible with appropriate dose adjustments rather than discontinuing completely, due to its demonstrated significant mortality and morbidity benefits in heart failure with reduced ejection fraction 1, 3