Would you recommend adding an alpha blocker to the treatment regimen for a patient with hypertension and ischemic heart disease?

Alpha Blockers Are Not Recommended for Hypertension in Patients with Ischemic Heart Disease

Alpha-1 blockers should only be considered as second-line agents in hypertensive patients with ischemic heart disease, and only when concomitant benign prostatic hyperplasia (BPH) is present. 1

Primary Recommendation

• Beta blockers, ACE inhibitors, or ARBs are the recommended first-line agents for hypertension in patients with stable ischemic heart disease (SIHD), with the addition of dihydropyridine calcium channel blockers or thiazide diuretics as needed for blood pressure control. 1
• Alpha-1 blockers (doxazosin, prazosin, terazosin) are classified as secondary agents in the 2017 ACC/AHA hypertension guidelines. 1

Why Alpha Blockers Are Not First-Line

Cardiovascular Outcomes Data

• The ALLHAT trial demonstrated that doxazosin was inferior to chlorthalidone for preventing cardiovascular disease events in high-risk hypertensive patients. 2
• Compared to diuretic therapy, alpha-blocker treatment resulted in:
  • 26% higher risk of stroke (RR 1.26; 95% CI 1.10-1.46) 2
  • 20% higher risk of combined cardiovascular disease (RR 1.20; 95% CI 1.13-1.27) 2
  • No difference in fatal CHD or nonfatal MI, but significantly worse secondary outcomes 2

Safety Concerns in Ischemic Heart Disease

• Alpha-1 blockers are associated with orthostatic hypotension, especially in older adults, which is particularly problematic in patients with coronary disease where maintaining adequate perfusion pressure is critical. 1
• The risk of hypotension-induced myocardial ischemia is a significant concern in this population. 1

When Alpha Blockers May Be Considered

The only compelling indication for alpha-1 blockers in hypertensive patients with ischemic heart disease is concomitant BPH. 1

• In this specific scenario, alpha-1 blockers may be added as second-line therapy after optimizing guideline-directed medical therapy (GDMT) with beta blockers, ACE inhibitors/ARBs, and other first-line agents. 1
• Dosing options include: doxazosin 1-16 mg daily, prazosin 2-20 mg 2-3 times daily, or terazosin 1-20 mg 1-2 times daily. 1, 3

Preferred Treatment Algorithm for Hypertension with Ischemic Heart Disease

1. Start with GDMT beta blockers (carvedilol, metoprolol succinate, bisoprolol, nadolol, or propranolol—avoid atenolol and those with intrinsic sympathomimetic activity) 1, 4, 5
2. Add ACE inhibitor or ARB for compelling indications (previous MI, stable angina, diabetes, LV dysfunction) 1
3. If angina persists with uncontrolled BP, add dihydropyridine calcium channel blocker (amlodipine or felodipine) 1
4. Add thiazide diuretic and/or mineralocorticoid receptor antagonist as needed for BP goal <130/80 mmHg 1
5. Consider alpha-1 blocker only if BPH is present and BP remains uncontrolled despite the above 1

Critical Pitfalls to Avoid

• Do not use alpha blockers as monotherapy or first-line treatment in patients with ischemic heart disease—the cardiovascular outcomes data do not support this approach. 2
• Monitor carefully for orthostatic hypotension, particularly in elderly patients or those on multiple antihypertensive agents. 1
• Avoid abrupt discontinuation of any antihypertensive agent, but particularly beta blockers in ischemic heart disease patients. 1