What medications have compelling indications for coronary artery disease (CAD) in patients with a history of myocardial infarction (MI) and hypertension?

Medications with Compelling Indications for CAD in Hypertensive Patients Post-MI

For hypertensive patients with a history of MI and CAD, beta-blockers (specifically GDMT beta-blockers: carvedilol, metoprolol succinate, bisoprolol, nadolol, propranolol, or timolol) and ACE inhibitors (or ARBs if ACE inhibitor intolerant) have compelling indications and should be used as first-line therapy. 1

First-Line Agents with Compelling Indications

Beta-Blockers (Class I Recommendation)

• GDMT beta-blockers are strongly recommended as first-line therapy for hypertension in patients with CAD and prior MI 1
• Specific agents with proven mortality benefit include:
  • Carvedilol
  • Metoprolol tartrate or metoprolol succinate
  • Bisoprolol
  • Nadolol
  • Propranolol
  • Timolol 1
• Avoid atenolol - it is less effective than placebo in reducing cardiovascular events and should not be used 1, 2
• Beta-blockers reduced all-cause mortality by 23% in randomized trials after MI 1
• It is reasonable to continue beta-blocker therapy beyond 3 years post-MI for long-term hypertension management 1

ACE Inhibitors or ARBs (Class I Recommendation)

• ACE inhibitors or ARBs are strongly recommended as first-line therapy alongside beta-blockers 1
• Ramipril produced a 22% reduction in MI, stroke, or CVD death compared with placebo over 5 years 1
• Perindopril reduced CVD death, MI, or cardiac arrest by 20% compared with placebo in patients with stable ischemic heart disease 1
• ACE inhibitors are particularly beneficial in patients with reduced ejection fraction or heart failure post-MI 1
• ARBs are recommended for patients who are ACE inhibitor intolerant 1

Additional Agents When Blood Pressure Goal Not Met

Dihydropyridine Calcium Channel Blockers

• Add dihydropyridine CCBs (e.g., amlodipine) if angina persists despite beta-blocker therapy and hypertension remains uncontrolled (Class I) 1
• Dihydropyridine CCBs are effective antianginal drugs that lower BP when added to beta-blockers 1
• Amlodipine is indicated to reduce risk of hospitalization for angina and coronary revascularization in documented CAD 3
• Avoid non-dihydropyridine CCBs (verapamil, diltiazem) in patients with reduced left ventricular ejection fraction 1

Thiazide Diuretics and Mineralocorticoid Receptor Antagonists

• Thiazide diuretics and/or MRAs can be added as needed to further control hypertension 1
• These agents should be used after optimizing beta-blockers and ACE inhibitors/ARBs 1

Blood Pressure Target

• Target BP should be <130/80 mm Hg in patients with CAD and hypertension 1
• Reduction of SBP to <130/80 mm Hg has been shown to reduce CVD complications by 25% and all-cause mortality by 27% 1

Treatment Algorithm

1. Initiate GDMT beta-blocker + ACE inhibitor (or ARB) as first-line therapy 1
2. If angina persists: Add dihydropyridine CCB to beta-blocker 1
3. If BP goal not met: Add thiazide diuretic, additional dihydropyridine CCB, and/or MRA 1
4. Continue beta-blocker therapy long-term (beyond 3 years post-MI is reasonable) 1

Critical Pitfalls to Avoid

• Never use atenolol - it lacks proven cardiovascular benefit and is inferior to other beta-blockers 1, 2
• Avoid beta-blockers with intrinsic sympathomimetic activity - they lack mortality benefit 1
• Do not use non-dihydropyridine CCBs (verapamil, diltiazem) in patients with heart failure with reduced ejection fraction 1
• Monitor for hypotension and renal dysfunction when initiating ACE inhibitors post-MI, as these occurred more frequently in clinical trials 4