What additional medications are recommended for a patient with hypertension urgency, significant heart failure with reduced ejection fraction, and coronary artery disease (CAD) already taking amlodipine (calcium channel blocker)?

Optimal Antihypertensive Medication Regimen for a Patient with Hypertension Urgency, HFrEF, and CAD

For a 71-year-old female with hypertension urgency, heart failure with reduced ejection fraction (HFrEF), and coronary artery disease (CAD) already on amlodipine 10 mg, the optimal additional medications should include an ACE inhibitor (or ARB), a beta-blocker, and an aldosterone receptor antagonist as this combination has been shown to improve mortality and morbidity outcomes.

First-Line Medications to Add

• ACE inhibitor or ARB: Should be added as first-line therapy as they have been shown to improve outcomes in patients with HFrEF and effectively lower blood pressure 1

  • Options include candesartan or valsartan (if using an ARB) which have shown equivalent benefit to ACE inhibitors in HFrEF 1
  • Consider starting at a low dose and titrating upward to maximize tolerability

• Beta-blocker: Should be added in conjunction with ACE inhibitor/ARB therapy 1

  • Specifically use evidence-based beta-blockers for HFrEF: carvedilol, metoprolol succinate, bisoprolol, or nebivolol 1
  • These agents have demonstrated mortality benefit in HFrEF while also providing blood pressure control 1

• Aldosterone receptor antagonist: Should be included if the patient has NYHA class II-IV HF with ejection fraction <40% 1

  • Options include spironolactone or eplerenone 1
  • Monitor serum potassium closely, especially when combined with ACE inhibitor/ARB 1
  • Do not use if serum creatinine ≥2.5 mg/dL in men or ≥2.0 mg/dL in women or if serum potassium ≥5.0 mEq/L 1

Diuretic Therapy

• Thiazide or thiazide-type diuretics: Should be used for BP control and to manage volume overload 1
  • Should be used together with an ACE inhibitor/ARB and beta-blocker 1
  • For severe HF (NYHA class III and IV) or severe renal impairment (eGFR <30 mL/min), loop diuretics are preferred for volume control, though they are less effective for BP reduction 1

Additional Considerations

• Sacubitril/valsartan: Consider as a replacement for ACE inhibitor if the patient remains symptomatic despite optimal treatment with an ACE inhibitor, beta-blocker, and aldosterone receptor antagonist 1

• Hydralazine plus isosorbide dinitrate: Should be added to the regimen if the patient is African American with NYHA class III or IV HFrEF 1

Medications to Avoid

• Non-dihydropyridine calcium channel blockers: Verapamil and diltiazem should be avoided due to their negative inotropic effects and risk of worsening HF 1

  • Note that amlodipine (which the patient is already taking) is generally safe in HFrEF based on the PRAISE trial 1, 2

• Alpha-blockers: Medications like doxazosin should only be used if other agents are inadequate to achieve BP control 1

• Clonidine and moxonidine: Should be avoided due to potential increased mortality risk in HF patients 1

• Hydralazine without nitrates: Should not be used alone 1

• NSAIDs: Use with caution due to effects on BP, volume status, and renal function 1

Blood Pressure Targets

• Target BP: <140/90 mmHg, with consideration for <130/80 mmHg if tolerated 1
• Monitor for orthostatic changes, especially in an elderly patient 1
• Avoid systolic BP <130 mmHg and diastolic BP <65 mmHg in octogenarians 1

Monitoring Recommendations

• Monitor serum potassium and renal function closely, especially when using ACE inhibitors/ARBs with aldosterone antagonists 1
• Assess for signs of worsening heart failure, especially when initiating new medications 1
• Monitor for orthostatic hypotension, particularly in elderly patients 1

Treatment Algorithm

1. Start with an ACE inhibitor (or ARB if ACE inhibitor not tolerated) at a low dose and titrate up as tolerated
2. Add a beta-blocker (carvedilol, metoprolol succinate, bisoprolol, or nebivolol) at a low dose and titrate up
3. Add an aldosterone antagonist if ejection fraction <40% and renal function permits
4. Add or adjust diuretic therapy based on volume status
5. Consider sacubitril/valsartan if the patient remains symptomatic despite optimal therapy
6. For African American patients with NYHA class III-IV, add hydralazine plus isosorbide dinitrate