Best Medication for Hypertension with Family History of Coronary Artery Disease
An ACE inhibitor (such as lisinopril 10-50 mg daily) or ARB (such as losartan 50-100 mg daily) is the recommended first-line medication for this patient, as these agents specifically reduce cardiovascular events in patients at risk for coronary artery disease. 1, 2
Primary Recommendation: ACE Inhibitor or ARB
ACE inhibitors and ARBs are specifically recommended as first-line therapy for hypertension in patients with coronary artery disease or at high cardiovascular risk, which applies to patients with a strong family history of CAD in relatively young parents (60s). 1
The American Diabetes Association and American Heart Association guidelines explicitly state that ACE inhibitors or ARBs are the preferred initial agents for patients with coronary artery disease, as they have demonstrated superior cardiovascular protection beyond blood pressure lowering alone. 1, 2
Start with lisinopril 10 mg once daily or losartan 50 mg once daily, titrating upward as needed for blood pressure control (maximum doses: lisinopril 40 mg, losartan 100 mg). 3, 4
Combination Therapy Strategy
If blood pressure is ≥160/100 mmHg, initiate combination therapy immediately with an ACE inhibitor or ARB plus either a thiazide-like diuretic (chlorthalidone or indapamide preferred) or a dihydropyridine calcium channel blocker. 1, 2
For blood pressure 140-159/90-99 mmHg, start with monotherapy and add a second agent if target is not achieved within 4 weeks. 2
Single-pill combination formulations are strongly preferred as they significantly improve medication adherence compared to separate pills. 1, 2
Additional Considerations for CAD Risk
Beta-blockers should be added if the patient develops angina, has a myocardial infarction, or has other compelling indications, but they are not recommended as first-line monotherapy for uncomplicated hypertension. 1, 2
The 2015 AHA/ACC/ASH Scientific Statement specifically recommends ACE inhibitors or ARBs as foundational therapy for hypertensive patients with coronary artery disease, with beta-blockers reserved for specific indications like post-MI or angina. 1, 5
Blood Pressure Target
Target blood pressure should be <130/80 mmHg for patients at high cardiovascular risk, including those with family history of premature CAD. 1
The 2024 ESC guidelines recommend targeting systolic BP of 120-129 mmHg in most adults if well tolerated, which is particularly appropriate for patients at elevated cardiovascular risk. 1
Critical Monitoring Parameters
Monitor serum creatinine, estimated GFR, and potassium levels at baseline and at least annually when using ACE inhibitors or ARBs, as these agents can cause hyperkalemia and acute kidney injury, particularly in patients with underlying renal dysfunction. 1
A modest increase in serum creatinine (up to 30% from baseline) during ACE inhibitor or ARB initiation is expected and actually identifies patients likely to experience long-term renal protective benefits. 6
Common Pitfalls to Avoid
Never combine an ACE inhibitor with an ARB, as this increases adverse events (hyperkalemia, syncope, acute kidney injury) without providing additional cardiovascular benefit. 1
Do not use beta-blockers as initial monotherapy unless there are specific indications such as angina, prior MI, or heart failure with reduced ejection fraction. 1, 2
Avoid abrupt discontinuation of beta-blockers if they are prescribed, as this can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias in patients with coronary artery disease. 7
Be aware that ACE inhibitors cause a persistent dry cough in approximately 10-20% of patients; if this occurs, switch to an ARB which has similar cardiovascular benefits without the cough side effect. 6, 8
Lifestyle Modifications
Concurrent lifestyle interventions are mandatory and include: sodium restriction (<2 g/day), weight loss if BMI >25 kg/m², Mediterranean or DASH diet, regular aerobic exercise, smoking cessation, and alcohol limitation to <100 g/week. 1
Dietary sodium loading can diminish or abolish the antihypertensive effect of ACE inhibitors, while salt restriction enhances their efficacy. 6