What are the key points for managing conditions like hypertension, heart failure, and coronary artery disease?

Key Management Strategies for Hypertension, Heart Failure, and Coronary Artery Disease

For optimal management of cardiovascular conditions like hypertension, heart failure, and coronary artery disease, a target blood pressure of <130/80 mmHg is recommended to reduce morbidity and mortality, with medication selection tailored to the specific cardiovascular condition. 1

Hypertension Management

Blood Pressure Targets

• Target BP <130/80 mmHg for most patients with hypertension, especially those with high cardiovascular risk or established cardiovascular disease 1
• For elderly patients or those with significant comorbidities, a slightly higher target of <140/90 mmHg may be appropriate 1

Treatment Algorithm

1. Lifestyle modifications (for all patients with BP >120/80 mmHg):

   • DASH-style eating pattern with reduced sodium (<2,300 mg/day) and increased potassium
   • Weight loss if overweight/obese
   • Physical activity (≥150 minutes/week moderate-intensity)
   • Moderation of alcohol intake 1

2. Pharmacologic therapy:

   • Initial BP 130-159/80-99 mmHg: Start with a single agent
   • Initial BP ≥160/100 mmHg: Start with two agents or single-pill combination 1

3. First-line medications:

   • ACE inhibitors or ARBs
   • Thiazide-like diuretics (chlorthalidone, indapamide preferred)
   • Dihydropyridine calcium channel blockers 1

Heart Failure Management

For Heart Failure with Reduced Ejection Fraction (HFrEF)

1. First-line therapies (all should be used together when possible):

   • ACE inhibitors/ARBs/ARNI
   • Beta-blockers
   • Mineralocorticoid receptor antagonists (MRAs)
   • SGLT2 inhibitors 1

2. Blood pressure management:

   • Target BP <130/80 mmHg but >120/70 mmHg
   • Avoid excessive BP lowering that could compromise organ perfusion 1

For Heart Failure with Preserved Ejection Fraction (HFpEF)

1. Recommended therapies:
   • SGLT2 inhibitors (Class 2a recommendation)
   • MRAs (Class 2b recommendation)
   • ARNi (Class 2b recommendation)
   • Aggressive treatment of hypertension (Class 1 recommendation) 1

Coronary Artery Disease Management

1. Blood pressure target: <130/80 mmHg 1, 2

2. Preferred medications:

   • Beta-blockers (especially post-MI or with active angina)
   • ACE inhibitors or ARBs (first-line for hypertension with CAD)
   • Calcium channel blockers (for angina control)
   • Statins for lipid management with LDL-C target <55 mg/dL (1.4 mmol/L) 1

3. For vasospastic angina:

   • Calcium channel blockers (Class I recommendation)
   • Nitrates (Class IIa recommendation) 1

Special Considerations

Diabetes with Hypertension

• Target BP <130/80 mmHg, especially with high cardiovascular risk
• ACE inhibitors or ARBs are preferred first-line agents, particularly with albuminuria 1

Resistant Hypertension

• Consider adding a mineralocorticoid receptor antagonist when BP not controlled on three medications including a diuretic 1
• Evaluate for secondary causes and medication adherence issues

Atrial Fibrillation with Hypertension

• Optimal BP control (target 120-129/70-79 mmHg) reduces stroke risk
• Anticoagulation based on CHA2DS2-VA score (hypertension adds 1 point) 1

Common Pitfalls to Avoid

1. Inappropriate combination therapy: Avoid combining ACE inhibitors with ARBs or direct renin inhibitors due to increased adverse effects without additional benefit 1

2. Underdosing medications: Titrate to maximum tolerated doses before adding additional agents

3. Overlooking non-adherence: Evaluate medication adherence at each visit before escalating therapy 1

4. Neglecting comorbidities: Address all cardiovascular risk factors comprehensively (diabetes, dyslipidemia, smoking)

5. Pregnancy considerations: ACE inhibitors, ARBs, and spironolactone are contraindicated in pregnancy; methyldopa, labetalol, and long-acting nifedipine are preferred 1

By implementing these evidence-based strategies for managing hypertension, heart failure, and coronary artery disease, clinicians can significantly reduce morbidity, mortality, and improve quality of life for patients with cardiovascular conditions.