From the Guidelines
The first-line treatment for hypertension (HRT) in the context of chronic coronary syndromes should prioritize beta-blockers and/or calcium channel blockers (CCBs) as initial therapy to reduce angina frequency and improve exercise tolerance. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, long-acting nitrates or ranolazine may be considered as add-on therapy in patients with inadequate control of symptoms while on treatment with beta-blockers and/or CCBs, or as part of initial treatment in properly selected patients. Some key points to consider when selecting first-line treatment include:
- The patient's heart rate, blood pressure, and tolerance to certain medications
- The presence of any contraindications to beta-blockers or CCBs
- The severity of symptoms and the need for rapid relief
- The potential for adverse effects and interactions with other medications In terms of specific medications, options may include:
- Beta-blockers such as metoprolol or atenolol
- CCBs such as amlodipine or nifedipine
- Long-acting nitrates such as isosorbide mononitrate or nitroglycerin
- Ranolazine, which may be used as an add-on therapy or as part of initial treatment in selected patients. It's essential to individualize treatment based on the patient's specific needs and circumstances, and to regularly reassess and adjust therapy as needed to optimize outcomes and minimize adverse effects, as recommended by the 2024 ESC guidelines 1.
From the Research
First-Line Treatment for HRT
- The first-line treatment for HRT is often a combination of estrogen and progestogen for women with an intact uterus 2.
- This combination is used to prevent endometrial hyperplasia, which can be caused by estrogen-only therapy 3.
- The choice of progestogen and the dosage of estrogen can vary, and lower doses of conjugated equine estrogens and medroxyprogesterone acetate have been shown to be effective in reducing the incidence of endometrial hyperplasia 4, 5.
Endometrial Effects of HRT
- Estrogen-only therapy can increase the risk of endometrial hyperplasia, which can be reduced by adding progestogen to the treatment regimen 3.
- The incidence of endometrial hyperplasia can vary depending on the dose and type of estrogen and progestogen used, as well as the duration of treatment 4, 5.
- Continuous combined HRT using low-dose progestin may increase the risk of endometrial cancer, although the evidence is limited and more research is needed to fully understand this risk 6.
Treatment Regimens
- Different treatment regimens, such as cyclical or continuous progestogen, can be used to manage HRT and reduce the risk of endometrial hyperplasia 2, 3.
- Lower doses of conjugated equine estrogens and medroxyprogesterone acetate can be effective in reducing the incidence of endometrial hyperplasia and may be considered for postmenopausal women who are candidates for hormone therapy 4, 5.