What are the best medications for treating hypertension in patients with congestive heart failure (CHF)?

Best Medications for Hypertension in Patients with Congestive Heart Failure

In patients with heart failure and hypertension, ACE inhibitors, ARBs, beta-blockers, and aldosterone receptor antagonists should be the first-line medications as they not only control blood pressure but also improve mortality and morbidity outcomes. 1

First-Line Medications for Hypertension in CHF

For Heart Failure with Reduced Ejection Fraction (HFrEF):

• ACE inhibitors (or ARBs if ACE inhibitors not tolerated) are cornerstone therapy for both hypertension control and improving heart failure outcomes 1
• Beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol) should be included in the regimen for their mortality benefit and BP-lowering effects 1
• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) should be added for patients with NYHA class II-IV symptoms and ejection fraction <40% 1
• SGLT2 inhibitors are recommended to improve outcomes in patients with HFrEF/HFmrEF 1
• Diuretics (thiazide or loop diuretics) should be used for volume control and BP management 1

For Heart Failure with Preserved Ejection Fraction (HFpEF):

• ACE inhibitors or ARBs are reasonable first-line agents for BP control 1
• SGLT2 inhibitors are recommended for patients with symptomatic HFpEF to improve outcomes 1
• ARBs and/or mineralocorticoid receptor antagonists may be considered to reduce hospitalizations and lower BP 1
• Diuretics should be prescribed for patients with volume overload 1

Medication Selection Algorithm

1. Start with an ACE inhibitor (e.g., lisinopril) or ARB if ACE inhibitor not tolerated 1, 2

   • Target maximum tolerated doses as higher doses provide greater benefits 3
   • Monitor renal function and potassium levels

2. Add a beta-blocker (preferably carvedilol, metoprolol succinate, or bisoprolol) 1

   • Carvedilol may be preferred in patients with refractory hypertension due to its additional alpha-blocking properties 1

3. Add a diuretic for volume control 1

   • Thiazide diuretics for mild volume overload and better BP control
   • Loop diuretics for severe HF or significant renal impairment

4. Add an aldosterone antagonist (spironolactone or eplerenone) 1

   • Particularly beneficial in resistant hypertension
   • Avoid if serum creatinine ≥2.5 mg/dL in men or ≥2.0 mg/dL in women, or if potassium ≥5.0 mEq/L

5. Consider SGLT2 inhibitors for additional benefits 1

6. For African American patients with NYHA class III-IV HF, add hydralazine plus isosorbide dinitrate to the regimen 1

Target Blood Pressure Goals

• For most patients with HF: target SBP 120-130 mmHg 1
• For older patients (≥65 years): target SBP 130-139 mmHg 1
• Avoid lowering DBP below 60 mmHg, especially in elderly patients or those with diabetes 1

Medications to Avoid in Heart Failure

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to negative inotropic effects 1
• Moxonidine and clonidine (centrally acting agents) 1
• Alpha-blockers such as doxazosin (use only if other medications inadequate) 1
• Hydralazine without nitrates 1
• NSAIDs (use with caution due to effects on BP, volume status, and renal function) 1

Special Considerations

• In resistant hypertension, consider adding spironolactone to existing treatment 1
• If spironolactone is not tolerated, consider eplerenone, higher dose diuretics, or adding bisoprolol or doxazosin 1
• For black patients, initial antihypertensive treatment should include a diuretic or CCB, either alone or with a RAS blocker 1
• Dihydropyridine CCBs (amlodipine, felodipine) can be used if BP remains uncontrolled after optimizing other medications 1

Monitoring and Follow-up

• Monitor renal function and electrolytes closely, especially when using ACE inhibitors, ARBs, or aldosterone antagonists 1
• Be aware of the paradox that in advanced HFrEF, lower BP may be associated with worse prognosis due to poor cardiac output 1
• Titrate medications gradually, especially in elderly patients or those with tenuous hemodynamics 1

Remember that the primary goal of hypertension treatment in heart failure patients is to improve mortality, morbidity, and quality of life while controlling blood pressure to target levels.