What is the first-line treatment of hypertension in a white male with Coronary Artery Disease (CAD)?

From the Guidelines

The first-line treatment for hypertension in a white male with Coronary Artery Disease (CAD) is an ACE inhibitor or ARB, with a thiazide or thiazide-like diuretic being a suitable alternative or addition, as recommended by the American Heart Association, American College of Cardiology, and American Society of Hypertension 1. When considering the management of hypertension in patients with CAD, it's crucial to prioritize medications that not only lower blood pressure but also provide specific benefits for CAD patients.

• ACE inhibitors, such as lisinopril, ramipril, or enalapril, are beneficial as they reduce angiotensin II formation, decrease afterload, prevent ventricular remodeling, and offer cardioprotective effects.
• ARBs can be used as an alternative to ACE inhibitors, especially if the patient experiences side effects such as cough.
• Thiazide or thiazide-like diuretics can be used alone or in combination with ACE inhibitors or ARBs, especially in patients without prior MI, LV systolic dysfunction, diabetes mellitus, or proteinuric CKD. The combination of a β-blocker, an ACE inhibitor or ARB, and a thiazide or thiazide-like diuretic should also be considered in the absence of a prior MI, LV systolic dysfunction, diabetes mellitus, or proteinuric CKD, as stated in the guidelines 1. It's also important to note that lifestyle and diet modifications, such as sodium restriction, increased intake of dietary potassium, weight loss if overweight/obese, appropriate physical activity, moderation of alcohol intake, and a healthy DASH-like diet, can be beneficial in managing hypertension, but are typically recommended in addition to, not instead of, medication in patients with CAD 1.
• The blood pressure target for patients with stable angina is <140/90 mm Hg, but a lower target BP (<130/80 mm Hg) may be considered in some individuals with CAD, with previous stroke or transient ischemic attack, or with CAD risk equivalents 1.

From the FDA Drug Label

The antihypertensive efficacy of amlodipine has been demonstrated in a total of 15 double-blind, placebo-controlled, randomized studies involving 800 patients on amlodipine and 538 on placebo Once daily administration produced statistically significant placebo-corrected reductions in supine and standing blood pressures at 24 hours postdose, averaging about 12/6 mmHg in the standing position and 13/7 mmHg in the supine position in patients with mild to moderate hypertension Effects on diastolic pressure were similar in young and older patients. The effect on systolic pressure was greater in older patients, perhaps because of greater baseline systolic pressure. Effects were similar in black patients and in white patients.

The first-line treatment of hypertension in a white male with Coronary Artery Disease (CAD) is amlodipine.

• The recommended dose is 5 to 10 mg once daily.
• Amlodipine has been shown to be effective in reducing blood pressure and angina symptoms in patients with CAD 2.
• The CAMELOT study demonstrated that amlodipine reduced the risk of hospitalization for angina and coronary revascularization in patients with CAD 2.

From the Research

First-Line Treatment of Hypertension in White Male with CAD

• The first-line treatment of hypertension in a white male with Coronary Artery Disease (CAD) is typically a thiazide diuretic, such as chlorthalidone, as it has been shown to be effective in reducing blood pressure and preventing cardiovascular events 3.
• Alternative options may include an angiotensin-converting enzyme (ACE) inhibitor, such as lisinopril, which has been shown to be beneficial in patients with CAD and left ventricular dysfunction or congestive heart failure 4.
• The use of calcium channel blockers (CCBs) as first-line therapy is not recommended, as they have been shown to be less effective than thiazide diuretics in reducing mortality and stroke 5.
• The selection of a specific antihypertensive medication should be based on individual patient characteristics, such as the presence of diabetes, renal disease, or left ventricular dysfunction.

Considerations for Patients with CAD

• Patients with CAD and left ventricular dysfunction or congestive heart failure should be treated with ACE inhibitors, as they have been shown to improve survival and reduce morbidity and mortality 4.
• In patients with CAD and diabetes, ACE inhibitors have been shown to be beneficial in reducing morbidity and mortality, and should be considered as first-line therapy 6.
• The use of CCBs in patients with CAD should be individualized, as they may be beneficial in certain patients, but have been shown to be less effective than thiazide diuretics in reducing mortality and stroke 5.

Clinical Evidence

• The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study found that thiazide diuretics were superior to CCBs and ACE inhibitors in preventing cardiovascular events 5.
• The Heart Outcomes Prevention Evaluation trial found that ACE inhibitors reduced morbidity and mortality in patients with CAD and diabetes 6.
• A review of the evidence found that thiazide diuretics were the most effective antihypertensive medication in reducing mortality and stroke, and should be considered as first-line therapy 3.