What are the initial antihypertensive (blood pressure lowering) medication recommendations for patients with hypertensive heart failure?

Initial Antihypertensive Medications for Hypertensive Heart Failure

For patients with hypertensive heart failure with reduced ejection fraction (HFrEF), initiate guideline-directed medical therapy (GDMT) with ACE inhibitors (or ARBs if ACE inhibitor intolerant), beta-blockers (carvedilol, metoprolol succinate, or bisoprolol), and mineralocorticoid receptor antagonists, titrated to maximal tolerated doses regardless of blood pressure, with diuretics added for volume overload. 1

Heart Failure with Reduced Ejection Fraction (HFrEF)

First-Line Therapy

Medications with compelling indications for HFrEF that simultaneously lower blood pressure include: 1

• ACE inhibitors or ARBs - These form the cornerstone of therapy, with ACE inhibitors preferred unless not tolerated 1
• Angiotensin receptor-neprilysin inhibitors (ARNi) - Sacubitril/valsartan provides superior blood pressure lowering compared to enalapril alone and reduces cardiovascular mortality in HFrEF 1
• GDMT beta-blockers - Specifically carvedilol, metoprolol succinate, or bisoprolol (NOT atenolol, which is less effective) 1
• Mineralocorticoid receptor antagonists - Spironolactone or eplerenone 1
• Diuretics - Essential for volume management; thiazide-type diuretics (particularly chlorthalidone) are highly effective 1

Blood Pressure Target

Target systolic blood pressure <130 mmHg in HFrEF patients, consistent with high cardiovascular risk reduction, though this specific target has not been proven by randomized trials in the HF population. 1

Medication Titration Strategy

Titrate all GDMT medications to maximal tolerated doses regardless of blood pressure level, as these agents reduce mortality and HF hospitalizations. 1 The 2017 ACC/AHA guideline emphasizes that no RCT evidence supports superiority of one BP-lowering medication over another specifically in HFrEF, but all the above agents have proven mortality benefits 1

Critical Medications to AVOID

Never use nondihydropyridine calcium channel blockers (verapamil, diltiazem) in HFrEF patients - these have myocardial depressant activity and demonstrate worse outcomes. 1

Avoid alpha-blockers (doxazosin) - the ALLHAT trial showed doxazosin doubled HF risk compared to chlorthalidone. 1

Heart Failure with Preserved Ejection Fraction (HFpEF)

First-Line Therapy

For HFpEF patients with volume overload, diuretics should be prescribed first to control hypertension and relieve symptoms. 1

After volume management, prescribe ACE inhibitors or ARBs plus beta-blockers, titrated to achieve systolic blood pressure <130 mmHg. 1

Additional Considerations for HFpEF

• SGLT2 inhibitors are recommended for symptomatic HFpEF patients given their modest BP-lowering properties and proven outcome benefits 1
• Mineralocorticoid receptor antagonists (spironolactone) may be considered in appropriately selected patients (EF ≥45%, elevated BNP, recent HF admission, eGFR >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L) to decrease hospitalizations 1
• ARBs and/or MRAs may be considered in patients with BP above target to reduce heart failure hospitalizations 1

Evidence Base for HFpEF

The evidence is weaker for HFpEF than HFrEF 1. Hypertension is present in 60-89% of HFpEF patients and is the most important cause 1. The TOPCAT trial showed spironolactone reduced HF hospitalization (HR 0.83) though the composite endpoint didn't reach statistical significance, with notable regional variation 1

Comparative Effectiveness Evidence

Thiazide Diuretics Show Superior HF Prevention

Chlorthalidone demonstrates superior efficacy over other antihypertensives for preventing both HFpEF and HFrEF. 1 In ALLHAT:

• Chlorthalidone reduced HFPEF risk by 31% vs amlodipine, 26% vs lisinopril, and 47% vs doxazosin 2
• Chlorthalidone reduced HFREF risk by 26% vs amlodipine and 39% vs doxazosin 2
• Most original trials used chlorthalidone rather than hydrochlorothiazide 1

Calcium Channel Blockers

Dihydropyridine calcium channel blockers (amlodipine) are less efficacious than thiazide diuretics or ACE inhibitors for preventing HF, though they can be added for refractory hypertension in HFpEF. 1, 3

Practical Implementation Algorithm

For HFrEF:

1. Start ACE inhibitor or ARB (or ARNi if appropriate) 1
2. Add GDMT beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) 1
3. Add mineralocorticoid receptor antagonist 1
4. Add diuretic for volume overload 1
5. Titrate all to maximum tolerated doses regardless of BP 1

For HFpEF:

1. Start diuretic if volume overload present 1
2. Add ACE inhibitor or ARB 1
3. Add beta-blocker 1
4. Consider SGLT2 inhibitor 1
5. Consider MRA if appropriate (based on TOPCAT criteria) 1
6. Target SBP <130 mmHg 1

Common Pitfalls

Do not withhold or reduce GDMT medications in HFrEF solely due to blood pressure concerns - these medications improve survival even if BP is already controlled 1, 4

Do not use nondihydropyridine CCBs in HFrEF - they worsen outcomes 1

Do not use alpha-blockers as first-line therapy - they increase HF risk 1

Lifestyle modifications remain essential adjuncts - weight reduction, sodium restriction (<2g/day), increased fruits/vegetables, and alcohol moderation enhance medication efficacy 1