Blood Pressure Medications in Congestive Heart Failure (CHF)
Medications to Avoid in CHF
Non-dihydropyridine calcium channel blockers (such as verapamil and diltiazem) should be avoided in patients with CHF due to their negative inotropic effects that can worsen heart failure symptoms. 1, 2
Other medications that should be avoided in CHF include:
- Alpha-adrenergic blockers (such as doxazosin) - associated with increased risk of developing heart failure 1
- Centrally acting agents (clonidine, moxonidine) - associated with increased mortality in heart failure patients 1
- Potent direct-acting vasodilators (minoxidil) - cause fluid retention due to renin-related effects 1
- Nonsteroidal anti-inflammatory drugs (NSAIDs) - can worsen renal function, increase fluid retention, and counteract beneficial effects of heart failure medications 1
Recommended Medications for CHF
First-line medications for CHF with hypertension include:
1. ACE Inhibitors
- Recommended for all patients with current or prior symptoms of heart failure and reduced ejection fraction 1
- Start with low doses and titrate upward gradually 1
- Examples and dosing:
2. Beta-Blockers
- Recommended for all stable patients with current or prior symptoms of heart failure and reduced ejection fraction 1
- Only use evidence-based beta-blockers proven to reduce mortality:
- Bisoprolol
- Carvedilol
- Metoprolol succinate (extended release) 1
3. Diuretics
- Essential for managing fluid retention in CHF 1
- Loop diuretics (furosemide, bumetanide, torsemide) for more severe heart failure 1
- Thiazide diuretics are more effective for BP control but less effective for severe volume overload 1
- Consider combination therapy with loop and thiazide diuretics for resistant cases 1
4. Angiotensin Receptor Blockers (ARBs)
- Recommended for patients who cannot tolerate ACE inhibitors (e.g., due to cough) 1
- Examples include candesartan and valsartan, which have shown benefit in heart failure 1
5. Aldosterone Antagonists
- Spironolactone or eplerenone recommended for severe heart failure (NYHA class III-IV) 1
- Monitor potassium levels carefully, especially when combined with ACE inhibitors or ARBs 1
6. Hydralazine/Isosorbide Dinitrate Combination
- Particularly beneficial in self-described Black patients with HFrEF 1
- Consider for patients who cannot tolerate ACE inhibitors or ARBs 1
Special Considerations
- When initiating ACE inhibitors, monitor renal function and potassium levels 1
- Small increases in creatinine (up to 50% above baseline) are expected and generally acceptable 1
- Dihydropyridine calcium channel blockers (amlodipine, felodipine) may be used if absolutely necessary for BP control in CHF patients 1
- The paradox of heart failure: once HFrEF is established, lower BP is associated with worse prognosis, while higher BP may indicate better cardiac output 1
- For patients with HF with preserved ejection fraction (HFpEF), controlling hypertension is particularly important for symptom management 1
Treatment Algorithm
- Start with ACE inhibitor (or ARB if intolerant) plus diuretic for fluid overload 1
- Add evidence-based beta-blocker once patient is stable 1
- Add aldosterone antagonist for severe symptoms 1
- Consider hydralazine/isosorbide dinitrate if additional BP control needed 1
- If BP remains uncontrolled, consider amlodipine (the only calcium channel blocker with neutral effect in CHF) 1
Common Pitfalls to Avoid
- Don't discontinue ACE inhibitors due to small increases in creatinine - clinical deterioration is likely if treatment is withdrawn 1
- Don't use alpha-blockers as first-line therapy for hypertension in CHF patients 1
- Don't use non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in patients with reduced ejection fraction 1, 2
- Don't overlook the importance of sodium restriction and fluid management alongside medication therapy 1