What is the best medication for a patient with chronic diastolic heart failure (HF) and hypertension?

Best Medications for Chronic Diastolic Heart Failure with Hypertension

For patients with chronic diastolic heart failure and hypertension, a combination therapy of diuretics (preferably thiazides), ACE inhibitors or ARBs, and beta-blockers should be used as first-line treatment. 1

First-Line Medication Regimen

1. Diuretics

• Thiazide diuretics are preferred for BP control and to reverse volume overload in patients with diastolic heart failure and hypertension 1
  • Options include hydrochlorothiazide (25 mg once or twice daily), chlorthalidone (12.5-25 mg once daily), or indapamide (2.5 mg once daily)
  • For severe heart failure or significant renal impairment, loop diuretics may be necessary 1

2. ACE Inhibitors or ARBs

• ACE inhibitors have shown efficacy in improving diastolic function 2
  • Lisinopril (starting at 5-10 mg daily, target dose 20-40 mg daily) 3
  • Shown to improve outcomes in heart failure patients when combined with diuretics 3
• ARBs (candesartan or valsartan) are equally effective alternatives if ACE inhibitors are not tolerated 1, 2

3. Beta-Blockers

• Evidence-based beta-blockers for heart failure include:
  • Carvedilol (target dose based on weight)
  • Metoprolol succinate (target dose 200 mg daily)
  • Bisoprolol (target dose 10 mg daily) 1
• Beta-blockers have been shown to reduce mortality in heart failure patients 1

Additional Therapies to Consider

4. Aldosterone Receptor Antagonists

• Spironolactone (12.5-25 mg daily) or eplerenone can be added to the regimen 1, 4
• Requires careful monitoring of potassium and renal function

5. For African American Patients

• Consider adding hydralazine/isosorbide dinitrate combination to the standard regimen in NYHA class III or IV heart failure 1

Target Blood Pressure

• Target BP should be <130/80 mmHg 1
• Consider further reduction to <120/80 mmHg if tolerated 1
• Monitor carefully for hypotension, especially in older patients or those with wide pulse pressures 1

Medications to Avoid

1. Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to negative inotropic effects 1
2. Clonidine and moxonidine due to potential increased mortality 1
3. Alpha-blockers like doxazosin (increased risk of heart failure) 1
4. NSAIDs (can worsen renal function and fluid retention) 4

Monitoring Protocol

1. Check electrolytes and renal function 1-2 weeks after initiation or dose changes 4
2. Monitor weight daily (patient should report increases of 1.5-2.0 kg over 2 days) 4
3. Adjust diuretic doses based on symptoms and signs of fluid retention 1
4. Regular follow-up to assess symptoms, vital signs, and medication tolerance 4

Common Pitfalls to Avoid

• Failure to titrate medications to target doses used in clinical trials 4
• Inadequate monitoring of renal function and electrolytes 4
• Insufficient diuresis in patients with fluid overload 4
• Not recognizing the need for loop diuretics in patients with severe renal impairment 1

Special Considerations

• In elderly patients (>60 years), be cautious about lowering diastolic BP below 60 mmHg 1
• For patients with diabetes, careful monitoring is needed when aggressively lowering blood pressure 1
• Non-pharmacological approaches including sodium restriction and a monitored exercise program should be implemented 1, 4

By following this medication algorithm and monitoring protocol, you can effectively manage both the diastolic heart failure and hypertension components of the disease, improving symptoms and potentially reducing hospitalizations and mortality.