Best Antihypertensive Medications for Reduced Systolic Heart Failure and Hypertension
For patients with reduced systolic heart failure and hypertension, a combination therapy including an ACE inhibitor or ARB, a beta-blocker (specifically carvedilol, metoprolol succinate, or bisoprolol), and a diuretic should be used as first-line treatment. 1
First-Line Therapy Algorithm
Foundation Medications (Class I; Level of Evidence A):
- ACE inhibitor (e.g., lisinopril) or ARB (if ACE inhibitor not tolerated)
- Beta-blocker (specifically carvedilol, metoprolol succinate, or bisoprolol)
- Diuretic (thiazide for mild cases, loop diuretic for severe HF)
Add-on Therapy:
- Aldosterone receptor antagonist (spironolactone or eplerenone) for NYHA class II-IV HF with ejection fraction <40% (Class I; Level of Evidence A)
- Hydralazine plus isosorbide dinitrate in African American patients with NYHA class III or IV (Class I; Level of Evidence A)
Specific Medication Recommendations
ACE Inhibitors/ARBs
ACE inhibitors are cornerstone therapy for patients with reduced systolic heart failure and hypertension. They reduce mortality, hospitalization rates, and improve symptoms 1. High-dose lisinopril (32.5-35 mg daily) has been shown to be more effective than low doses in reducing the risk of death or hospitalization and resulted in 24% fewer hospitalizations for heart failure 2.
Beta-Blockers
Only specific beta-blockers have proven mortality benefits in heart failure:
- Carvedilol
- Metoprolol succinate (extended-release)
- Bisoprolol
These agents have been shown to improve outcomes for patients with HF with reduced ejection fraction 1. The COPERNICUS trial demonstrated benefits of carvedilol even in patients with SBP as low as 85 mmHg 1.
Diuretics
- Thiazide diuretics are preferred for BP control in mild heart failure
- Loop diuretics (furosemide, torsemide) should be used for volume control in severe HF or renal impairment, though they are less effective than thiazides for BP lowering 1
Aldosterone Receptor Antagonists
Spironolactone or eplerenone should be added to the regimen for patients with NYHA class II-IV heart failure with reduced ejection fraction (<40%) 1. The RALES trial showed a 30% reduction in total mortality with spironolactone, while the EPHESUS trial demonstrated a 15% improvement in mortality with eplerenone 1.
Target Blood Pressure
The target BP in patients with heart failure should be <130/80 mmHg, with consideration given to lowering BP even further to <120/80 mmHg in some patients 1.
Medications to Avoid
Several classes of drugs should be avoided in patients with reduced systolic heart failure and hypertension:
Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to negative inotropic properties and risk of worsening HF symptoms 1
Clonidine and moxonidine - moxonidine was associated with increased mortality in HF patients 1
Alpha-blockers (e.g., doxazosin) - the doxazosin arm in the ALLHAT trial was discontinued due to a 2.04-fold increase in relative risk of developing HF compared to chlorthalidone 1
NSAIDs - can cause sodium retention, peripheral edema, and worsen renal function 1, 3
Special Considerations
Monitoring: Check renal function and potassium levels 1-4 weeks after starting ACE inhibitors or ARBs, especially in patients with renal insufficiency 3
Dose Titration: ACE inhibitors and beta-blockers should be titrated to target doses used in clinical trials when possible 2, 4
Combination Therapy: The combination of ACE inhibitor + ARB is generally not recommended due to increased risk of adverse effects without substantial benefit 3
Lifestyle Modifications: Sodium restriction and a closely monitored exercise program are recommended as part of the treatment approach 1
By following this evidence-based approach to antihypertensive therapy in patients with reduced systolic heart failure, clinicians can optimize outcomes in terms of mortality reduction, symptom improvement, and prevention of hospitalizations.