What are the recommended medications for hypertension (HTN) in patients with coronary artery disease (CAD)?

Hypertension Management in Coronary Artery Disease Patients

For hypertensive patients with CAD, start with a β-blocker (especially if prior MI), add an ACE inhibitor or ARB (particularly with prior MI, LV dysfunction, diabetes, or CKD), and include a thiazide or thiazide-like diuretic as foundational therapy. 1

First-Line Medication Regimen

Core Triple Therapy

• β-blocker: Mandatory in patients with prior MI; strongly recommended for all CAD patients with hypertension 1

  • Preferred agents: carvedilol, metoprolol succinate, metoprolol tartrate, nadolol, bisoprolol, propranolol, or timolol 1
  • Avoid atenolol - it is less effective than placebo in reducing cardiovascular events 1
  • Avoid β-blockers with intrinsic sympathomimetic activity 1

• ACE inhibitor or ARB: Class I recommendation, particularly compelling with prior MI, LV systolic dysfunction, diabetes mellitus, or CKD 1

  • Both classes show equivalent benefit in reducing cardiovascular events 1

• Thiazide or thiazide-like diuretic: Essential component of the regimen for blood pressure control 1

  • Chlorthalidone is preferred as a thiazide-like agent 1

This triple combination should be considered even in the absence of prior MI, LV dysfunction, diabetes, or proteinuric CKD (Class IIa recommendation) 1

Add-On Therapy for Uncontrolled Hypertension or Angina

When to Add Calcium Channel Blockers

• Long-acting dihydropyridine CCB (e.g., amlodipine 5-10 mg once daily): Add to the basic triple regimen if either angina or hypertension remains uncontrolled 1, 2
  • This is a Class IIa recommendation with Level of Evidence B 1
  • Amlodipine specifically demonstrated a 31% reduction in composite cardiovascular endpoints and 42% reduction in hospitalizations for angina in the CAMELOT trial 3

β-blocker Substitution Strategy

• If β-blockers are contraindicated or cause intolerable side effects: Substitute with a nondihydropyridine CCB (diltiazem or verapamil) 1
  • Critical caveat: Do NOT use nondihydropyridine CCBs if LV dysfunction is present 1
  • Warning: Combining β-blockers with nondihydropyridine CCBs increases risk of significant bradyarrhythmias and heart failure 1

Blood Pressure Targets

Standard Target

• <140/90 mm Hg for patients with stable angina (Class I; Level of Evidence A) 1

Lower Target Consideration

• <130/80 mm Hg may be considered in select individuals with: 1
  • Previous stroke or transient ischemic attack
  • CAD risk equivalents (carotid artery disease, PAD, abdominal aortic aneurysm)
  • Prior MI
  • This is a Class IIb recommendation with Level of Evidence B 1

Critical Diastolic Blood Pressure Caution

• Avoid diastolic BP <60 mm Hg, especially in patients with myocardial ischemia 1
• In octogenarians, avoid systolic BP <130 mm Hg and diastolic BP <65 mm Hg 1
• Monitor carefully for signs of myocardial ischemia when lowering systolic BP causes very low diastolic values 1

Special Populations and Situations

Post-MI Patients

• Continue β-blockers beyond 3 years as long-term therapy for hypertension (Class IIa recommendation) 1
• β-blockers are superior to all other drug classes after recent MI 4
• Early intervention with IV β-blockers within 12 hours results in 15% reduction in cardiovascular mortality at 1 week 5
• Oral non-ISA β-blockers started 3-28 days post-MI result in 30% reduction in mortality after 1 year 5

Heart Failure with Reduced Ejection Fraction

• Add aldosterone receptor antagonists (spironolactone or eplerenone) if NYHA class II-IV with ejection fraction <40% 1

  • Do NOT use if serum creatinine ≥2.5 mg/dL (men) or ≥2.0 mg/dL (women), or if serum potassium ≥5.0 mEq/L 1
  • Monitor potassium frequently when combined with ACE inhibitor or ARB 1

• Drugs to AVOID in HF with reduced ejection fraction: 1

  • Nondihydropyridine CCBs (verapamil, diltiazem) - Class III Harm
  • Clonidine, moxonidine
  • Hydralazine without a nitrate
  • α-adrenergic blockers (use only if other drugs inadequate at maximum doses)

Acute Coronary Syndromes

• In patients with uncontrolled severe hypertension taking antiplatelet or anticoagulant drugs, lower BP without delay to reduce hemorrhagic stroke risk 1

Common Pitfalls to Avoid

1. Do not use atenolol - inferior outcomes compared to other β-blockers 1
2. Do not combine β-blockers with nondihydropyridine CCBs unless absolutely necessary due to bradyarrhythmia risk 1
3. Do not use nondihydropyridine CCBs in LV dysfunction - Class III Harm 1
4. Do not lower diastolic BP below 60 mm Hg - risk of worsening myocardial ischemia 1, 4
5. Do not use nitrates with phosphodiesterase inhibitors (sildenafil-type drugs) 1

Adjunctive Therapies

• Long-acting nitrates: Can be added for angina relief when β-blockers alone are insufficient 1
  • Note: Nitrates are not effective for hypertension management per se 1
• Antiplatelet drugs and lipid-lowering agents: No special contraindications in hypertensive CAD patients 1