What is the management plan for a patient with hypertension, recent history of left-sided Bell's palsy, chest pain, mild aortic regurgitation (AR), and mild left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 45-50% and microvascular dysfunction?

Management Plan for Hypertension with Mild LV Systolic Dysfunction, Microvascular Dysfunction, and Bell's Palsy

For this patient with hypertension, recent left-sided Bell's palsy, chest pain, mild aortic regurgitation (AR), mild LV systolic dysfunction (LVEF 45-50%), and microvascular dysfunction, an ACE inhibitor should be the cornerstone of therapy, combined with a beta-blocker and possibly a diuretic if needed for blood pressure control.

Primary Management Strategy

Antihypertensive Therapy

• First-line therapy: ACE inhibitor is recommended as the foundation of treatment due to the patient's mild LV systolic dysfunction (LVEF 45-50%) 1
• Beta-blocker should be added as a second agent due to:
  • Presence of chest pain (likely from microvascular dysfunction) 1
  • Mild LV systolic dysfunction 1
• If blood pressure remains uncontrolled, add a thiazide-like diuretic as a third agent 1
• Target blood pressure should be <130/80 mmHg; consider even lower targets (<120/80 mmHg) given the presence of LV dysfunction 1

Management of Microvascular Dysfunction

• Long-acting dihydropyridine calcium channel blocker (e.g., amlodipine) can be added if angina persists despite beta-blocker therapy 1
• Consider long-acting nitrates if angina remains uncontrolled with the above regimen 1
• Antiplatelet therapy should be considered for microvascular dysfunction 1, 2

Management of Mild Aortic Regurgitation

• ACE inhibitors are preferred for patients with aortic regurgitation who require BP-lowering treatment 1
• Avoid excessive reduction in diastolic blood pressure (keep DBP >60 mmHg) to maintain coronary perfusion 1
• Regular echocardiographic follow-up every 1-2 years to monitor AR progression and LV dimensions 1

Rationale for Medication Choices

Why ACE Inhibitors as First-Line

• ACE inhibitors reduce mortality and morbidity in patients with LV systolic dysfunction 1
• They provide beneficial effects on LV fibrosis and remodeling 1
• Superior to ARBs for reducing cardiovascular events in patients with LV dysfunction 3, 4
• Beneficial in patients with microvascular dysfunction by improving endothelial function 2

Why Beta-Blockers as Second-Line

• Reduce myocardial oxygen demand, beneficial for chest pain 1
• Improve survival in patients with LV systolic dysfunction 1
• Recommended in patients with symptomatic CAD and hypertension 1

Special Considerations

Bell's Palsy History

• No specific contraindications for antihypertensive medications due to Bell's palsy history
• Monitor for any neurological symptoms during medication adjustments

Mild LV Systolic Dysfunction

• Consider ARNI (sacubitril/valsartan) if patient remains symptomatic despite optimal therapy with ACE inhibitor and beta-blocker 5
• Regular monitoring of ejection fraction is essential; if LVEF decreases below 40%, intensify heart failure therapy 1

Microvascular Dysfunction

• Aggressive risk factor modification including optimal BP control is essential 2
• Consider statin therapy regardless of lipid levels for endothelial benefits 2

Monitoring Plan

• Blood pressure monitoring: Office BP measurements at each visit and home BP monitoring 1
• Renal function and electrolytes: Check 1-2 weeks after initiation or dose adjustment of ACE inhibitor 1
• Echocardiography: Every 6-12 months to monitor LV function and aortic regurgitation 1
• Symptom assessment: Regular evaluation of chest pain and heart failure symptoms 1

Potential Pitfalls and Caveats

• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to LV dysfunction 1, 6
• Monitor for orthostatic hypotension, especially when initiating therapy 1
• Start with lower doses of ACE inhibitors and titrate gradually to avoid hypotension 1
• If ACE inhibitor causes intolerable cough, switch to an ARB 1, 7
• Avoid excessive lowering of diastolic blood pressure (<60 mmHg) in patients with coronary artery disease 1