How to manage hypertension in a patient with DM, HTN, ESRD, previous CVA, and EF of 20% on Hydralazine, Metoprolol, and Entresto (sacubitril and valsartan)?

Management of Hypertension in a Patient with DM, HTN, ESRD, Previous CVA, and EF of 20%

For this patient with severe hypertension (202/103 mmHg), ESRD, heart failure with reduced ejection fraction (HFrEF), and previous CVA, the current regimen should be modified to add spironolactone as a fourth agent to control blood pressure while maintaining optimal heart failure therapy. 1

Current Clinical Situation Assessment

• Patient has severe hypertension (202/103 mmHg) despite being on:

  • Hydralazine 100 mg TID
  • Metoprolol 100 mg OD
  • Entresto (sacubitril/valsartan) 100 mg BID 2

• Complicating factors:

  • End-stage renal disease (ESRD)
  • Diabetes mellitus (DM)
  • Previous cerebrovascular accident (CVA)
  • Severely reduced ejection fraction (EF 20%) 1

Recommended Management Approach

Step 1: Optimize Current Medications

• Continue Entresto (sacubitril/valsartan) as it is indicated for heart failure with reduced ejection fraction and provides both angiotensin receptor blockade and neprilysin inhibition 2, 3

• Continue Metoprolol as beta-blockers are recommended for patients with HFrEF. Metoprolol succinate is one of the four beta-blockers proven to reduce mortality in HF patients 1

• Reassess Hydralazine dosing - While hydralazine is recommended in HF patients, it is typically used in combination with isosorbide dinitrate, particularly in African American patients with advanced heart failure 1

Step 2: Add Additional Agents

• Add spironolactone to the existing regimen as it:

  • Is beneficial in resistant hypertension 1
  • Improves outcomes in heart failure with reduced ejection fraction 1
  • Has been shown to reduce mortality by 30% in patients with NYHA class III or IV heart failure 1
  • Start at a low dose (12.5-25 mg daily) with careful monitoring of potassium levels 1

• If spironolactone is not tolerated, consider:

  • Eplerenone as an alternative aldosterone antagonist 1
  • Adding a loop diuretic if not already prescribed, given the patient's ESRD status 1

Step 3: Blood Pressure Target

• Target blood pressure should be <130/80 mmHg as recommended for patients with:

  • Diabetes mellitus
  • Chronic kidney disease
  • Established cardiovascular disease 1

• Consider a more gradual approach to BP reduction given the patient's multiple comorbidities, aiming for no more than 20-25% reduction in mean arterial pressure initially to avoid hypoperfusion 1

Step 4: Monitoring and Follow-up

• Monitor for hypotension as sacubitril/valsartan, beta-blockers, and aldosterone antagonists can all lower blood pressure 2

• Monitor renal function and electrolytes closely, especially potassium, given the patient's ESRD and multiple medications affecting the renin-angiotensin-aldosterone system 2

• Assess volume status regularly as patients with ESRD and heart failure require careful volume management 1

Special Considerations

• ESRD implications: Limited data exists on sacubitril/valsartan use in dialysis patients, but observational studies suggest potential benefits for resistant hypertension and left ventricular dysfunction in ESRD 4

• Heart failure with reduced EF: The combination of ACEI/ARB (or ARNI), beta-blocker, and aldosterone antagonist forms the cornerstone of therapy for HFrEF 1

• Previous CVA: Blood pressure control is essential to prevent recurrent stroke, but avoid excessive or rapid BP reduction 1

• Caution with hydralazine monotherapy: While hydralazine is included in the current regimen, evidence for its use as monotherapy in hypertension is limited, and it's typically recommended in combination with nitrates for heart failure 1

Common Pitfalls to Avoid

• Excessive BP reduction: Avoid lowering BP too rapidly or excessively, which could compromise cerebral or coronary perfusion, especially with the patient's history of CVA and reduced EF 1

• Hyperkalemia risk: The combination of ESRD and multiple RAAS-blocking agents (Entresto and aldosterone antagonists) increases hyperkalemia risk, requiring vigilant monitoring 2

• Volume depletion: Excessive diuresis can worsen renal function and cause hypotension, particularly in patients with ESRD and heart failure 1

• Drug interactions: Be aware of potential interactions between the multiple cardiovascular medications this patient requires 2

By following this approach, the patient's blood pressure should be better controlled while maintaining optimal therapy for heart failure with reduced ejection fraction.