From the Guidelines
For a patient with hypertension, bradycardia, chronic diastolic heart failure, acute kidney failure, and CKD3b, the most appropriate medication regimen would likely be a combination of hydralazine and isosorbide dinitrate for blood pressure control, along with low-dose loop diuretics such as furosemide (starting at 20-40mg daily) or torsemide (10-20mg daily). This recommendation is based on the guidelines provided by the American College of Cardiology and American Heart Association, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
The hydralazine/nitrate combination provides afterload and preload reduction without worsening kidney function or heart rate, making it a suitable choice for patients with bradycardia and acute kidney failure. Loop diuretics, such as furosemide or torsemide, are preferred over thiazides due to their effectiveness in reduced kidney function, as stated in the guidelines 1.
Key considerations in managing this patient include:
- Avoiding beta-blockers and calcium channel blockers due to the presence of bradycardia
- Avoiding ACE inhibitors and ARBs due to the acute kidney failure
- Careful monitoring of electrolytes, kidney function, and blood pressure, with dose adjustments based on clinical response
- Implementing fluid restriction (typically 1.5-2L daily) and daily weight monitoring to complement pharmacological therapy
This approach prioritizes the management of blood pressure and fluid overload while protecting the compromised cardiac and renal systems, in line with the recommendations from the American Heart Association 1.
From the Research
Medication Options for HTN, BRADY Cardia, and Chronic Diastolic Congestive Heart Failure
- For patients with heart failure and chronic kidney disease (CKD), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) have been shown to be beneficial in managing heart failure with morbidity and mortality benefits 2.
- SGLT-2 inhibitors are now recommended as first-line therapy in people with diabetes, CKD, and heart failure, as they have been shown to reduce the risk of heart failure events and hospitalizations 3.
- Nonsteroidal mineralocorticoid receptor antagonists (nsMRA) and GLP-1 receptor agonists are also being investigated as potential therapeutic approaches for managing hypertension and CKD in patients with heart failure 3.
Considerations for Patients with Acute Kidney Failure and CKD3b
- Patients with comorbid heart failure and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction 4.
- The use of "triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist may be beneficial in patients with heart failure and reduced ejection fraction, but its use is lower in patients with lower eGFR 4.
- Renal microcirculatory dysfunction may play a critical role in the pathogenesis of cardiac surgery-associated acute kidney injury in patients with heart failure and CKD 5.
Updates from the 2021 ESC Guidelines
- The 2021 European Society of Cardiology guidelines emphasize the importance of identifying the three phenotypes of heart failure to guide appropriate evidence-based management 6.
- A new and simplified treatment algorithm for heart failure with reduced ejection fraction involves the rapid sequential initiation and up-titration of four 'pillars' of drug treatment, including sodium-glucose co-transporter 2 inhibitors 6.
- Updated treatment plans are available for heart failure associated with non-cardiovascular comorbidities, including CKD 6.