What medications are used to manage decompensated heart failure (HF) with hypertension (Htn) in black men?

Medication Management for Decompensated Heart Failure with Hypertension in Black Men

For black men with decompensated heart failure and hypertension, first-line therapy should include diuretics, ACE inhibitors or ARBs, beta-blockers, and the combination of isosorbide dinitrate and hydralazine, which has shown a 43% decrease in mortality specifically in this population. 1

First-Line Medications

Diuretics

• Thiazide diuretics are recommended for BP control and to reverse volume overload in patients with decompensated HF 1
• Loop diuretics (e.g., furosemide) should be used for severe HF or in patients with severe renal impairment, although they are less effective than thiazide diuretics in lowering BP 1
• Diuretics should be used in conjunction with other HF medications rather than as monotherapy 1

ACE Inhibitors/ARBs

• ACE inhibitors or ARBs should be included in the standard regimen, though they may be less effective for BP control in black patients compared to other racial groups 1
• ARBs like losartan can be used if ACE inhibitors are not tolerated 1, 2
• Black patients with HF may experience more hospitalizations with ACE inhibitors compared to white patients, though mortality benefits remain similar 1

Beta-Blockers

• Carvedilol, metoprolol succinate, and bisoprolol have been shown to improve outcomes in HF and are effective in lowering BP 1
• Carvedilol has demonstrated similar benefit magnitude in both black and non-black patients with HF 1
• Avoid bucindolol in black patients as it has shown a nonsignificant increase in risk of serious clinical events 1

Hydralazine/Isosorbide Dinitrate Combination

• This combination should be added to the standard regimen in black patients with NYHA class III or IV HF 1
• A randomized trial specifically in black patients showed 43% decrease in mortality and improved time to first hospitalization and quality of life 1, 3
• The mechanism may be related to improvement in nitric oxide bioavailability 1, 3

Second-Line Medications

Aldosterone Receptor Antagonists

• Spironolactone or eplerenone should be included for patients with severe HF (NYHA class III or IV, or LVEF <40% with clinical HF) 1, 4
• These medications have been shown to be beneficial in HF and can help manage edema 1, 4

Calcium Channel Blockers

• Dihydropyridine CCBs (like amlodipine) may be considered if other medications fail to achieve BP control 1
• Amlodipine has been shown to be as effective as chlorthalidone in reducing BP, CVD, and stroke events in black patients 1

Medications to Avoid

• Non-dihydropyridine calcium channel blockers (verapamil and diltiazem) should be avoided as they can depress myocardial function 1
• Clonidine and moxonidine should be avoided in patients with HF and hypertension 1
• Alpha-adrenergic blockers like doxazosin should only be used if other medications fail to achieve BP control at maximum tolerated doses 1

Treatment Considerations Specific to Black Patients

• Black patients develop HF symptoms at an earlier average age than non-black patients 1
• HF progresses more rapidly in black than white patients, with higher risk of initial and recurrent hospitalizations 1, 5
• Hypertension is more common in black patients (44% prevalence) and often more resistant to treatment 6
• In black patients, thiazide diuretics or CCBs are more effective in lowering BP than RAS inhibitors or beta-blockers 1
• Target BP should be <130/80 mmHg, with consideration for lowering further to <120/80 mmHg 1

Management Algorithm

1. Initial stabilization: IV loop diuretics for volume overload and congestion 7, 8
2. Establish maintenance therapy:
   • Diuretic (thiazide preferred if renal function allows) 1
   • ACE inhibitor or ARB 1, 2
   • Beta-blocker (preferably carvedilol) 1
   • Hydralazine/isosorbide dinitrate combination 1
3. Add if severe HF persists:
   • Aldosterone receptor antagonist (spironolactone or eplerenone) 1, 4
4. For resistant hypertension:
   • Consider adding dihydropyridine CCB 1

Important Caveats

• Black patients are underrepresented in most clinical trials of HF, which compromises extrapolation of results 1, 6
• Closely monitor renal function and electrolytes, particularly potassium, when using ACE inhibitors, ARBs, and aldosterone antagonists 4
• When initiating beta-blockers in patients with decompensated HF, use specific care and initially low doses 1
• The combination of ACE inhibitors and ARBs should be avoided due to increased risk of adverse effects without additional benefit 1