From the Guidelines
Heart failure with hypertension is a serious condition that requires aggressive management of blood pressure to reduce the risk of incident heart failure and heart failure hospitalization.
Key Management Strategies
- Lifestyle changes: Recommended, including diet and exercise 1
- Blood pressure targets: Should be lowered to <130/80 mm Hg, but >120/70 mm Hg 1
- Medications:
- RAS blockers: Effective in improving clinical outcome in patients with established HFrEF 1
- Beta-blockers: Effective in improving clinical outcome in patients with established HFrEF 1
- Mineralocorticoid receptor antagonists: Effective in improving clinical outcome in patients with established HFrEF 1
- Angiotensin receptor-neprilysin inhibitor (ARNI): Indicated for the treatment of HFrEF as an alternative to ACE inhibitors or ARBs 1
- Diuretics: Limited evidence to symptomatic improvement, but can be used for volume control 1
- Calcium channel blockers: Indicated only in case of poor blood pressure control 1
Specific Considerations
- HFrEF: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are effective in improving clinical outcome 1
- HFpEF: Optimal treatment strategy is not known, but ARNI can be considered as an alternative to ACE inhibitors or ARBs 1
- Diastolic heart failure: No evidence on the superiority of specific antihypertensive drugs, but aggressive treatment with multiple drugs is recommended 1
General Principles
- Blood pressure control: Is crucial in reducing the risk of incident heart failure and heart failure hospitalization 1
- Global management of risk: Including metabolic factors and obesity, is important in addition to aggressive antihypertensive therapy 1
From the Research
Heart Failure with Hypertension
- Hypertension is a primary and common risk factor leading to the development of heart failure (HF) across the entire spectrum of left ventricular ejection fraction 2.
- Adequate blood pressure (BP) control can reduce cardiovascular events, including the development of HF 2, 3, 4.
- The management of hypertension in HF relies on the extrapolation of findings from high-risk hypertensive patients in the general population and not from specifically designed studies in HF populations 2.
Treatment Strategies
- In patients with hypertension and HF with reduced ejection fraction (HFrEF), it is recommended to combine drugs with documented outcome benefits and BP-lowering effects 2, 5.
- In patients with HF with preserved EF (HFpEF), a therapeutic strategy with all major antihypertensive drug classes is recommended 2.
- Type 2 sodium glucose transporter inhibitors (SGLT2i) have been shown to induce BP-lowering actions that favorably affect cardiac afterload, ventricular arterial coupling, cardiac efficiency, and cardiac reverse remodeling 2.
- Finerenone, a non-steroidal mineralocorticoid receptor antagonist, reduces new-onset HF and improves other HF outcomes in patients with chronic kidney disease and type 2 diabetes, irrespective of a history of HF 2.
Blood Pressure Management
- Guidelines consensually recommend treating hypertension with drugs that have compelling indications in heart failure, with a target blood pressure of 130/80 mmHg in patients with HFrEF 5.
- In patients with HFpEF, guidelines acknowledge that the optimal treatment strategy remains unclear and thus recommend adopting a similar treatment strategy to patients with reduced ejection fraction 5.
- Low blood pressure should not deter uptitration of drugs otherwise indicated to improve prognosis in heart failure, provided that patients tolerate drugs without adverse events 5.
- Special considerations and treatment adjustments are needed in the elderly as well as in patients with diabetes, chronic kidney disease, and atrial fibrillation 5.