What is the best approach to manage uncontrolled hypertension in a patient with cardiac myopathy, atrial fibrillation, valvular regurgitation, and HFpEF, currently on valsartan and HCTZ, with a history of leg swelling on amlodipine?

Management of Uncontrolled Hypertension in HFpEF with Cardiac Comorbidities

Add an SGLT2 inhibitor (such as empagliflozin or dapagliflozin) to the current regimen of valsartan and HCTZ, and consider adding a beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) to target SBP <130 mmHg while providing additional benefit for atrial fibrillation rate control. 1

Primary Recommendation: SGLT2 Inhibitor Addition

• SGLT2 inhibitors are specifically recommended (Class I) for hypertensive patients with HFpEF to improve outcomes in the context of their modest BP-lowering properties. 1
• This represents the most recent (2024) and highest-quality guideline recommendation for this exact clinical scenario 1
• SGLT2 inhibitors provide mortality and morbidity benefits in HFpEF beyond simple BP reduction 1

Secondary Addition: Beta-Blocker Therapy

• Beta-blockers should be added for patients with HFpEF and persistent hypertension after volume management, with evidence showing 14-35% mortality reduction. 1
• The 2017 ACC/AHA guidelines specifically recommend ACE inhibitors or ARBs (already on valsartan) AND beta-blockers to attain SBP <130 mmHg in HFpEF 1
• Beta-blockers provide the additional benefit of ventricular rate control for atrial fibrillation (Class I recommendation) 1
• Use carvedilol, metoprolol succinate, or bisoprolol—these are the three evidence-based options 2

Blood Pressure Target

• Target SBP should be 120-129 mmHg based on the most recent 2024 ESC guidelines. 1
• The 2017 ACC/AHA guidelines recommend SBP <130 mmHg for HFpEF patients 1
• This patient's current SBP in the 170s represents significant uncontrolled hypertension requiring urgent intensification 1

Diuretic Optimization

• Continue HCTZ 25mg as diuretics are the only agents that adequately control fluid retention in HF and are essential for BP control in HFpEF (Class I recommendation). 1
• Diuretics should be prescribed to all patients with HFpEF who have evidence of volume overload 1
• The current HCTZ dose is appropriate; thiazide diuretics are preferred over loop diuretics for BP control unless severe HF or renal impairment is present 1

Valsartan Dose Assessment

• The current valsartan dose of 325mg exceeds the maximum recommended dose of 320mg daily. 3
• Consider reducing to 320mg (maximum FDA-approved dose) or 160mg if adding multiple agents 3
• ARBs like valsartan are appropriate for HFpEF and reduce HF hospitalizations 1

Why Not Restart Amlodipine

• Amlodipine should NOT be restarted given the documented leg swelling, which represents a common adverse effect (9.7-17.1% incidence). 4
• While amlodipine is safe in HFpEF (PRAISE trial), peripheral edema is a class effect of dihydropyridine calcium channel blockers that worsens with higher doses 1
• The patient's leg swelling history makes CCBs a poor choice despite their efficacy 4

Mineralocorticoid Receptor Antagonist Consideration

• Consider adding spironolactone or eplerenone if BP remains uncontrolled after SGLT2i and beta-blocker addition, particularly given the cardiac myopathy. 1
• MRAs provide substantial mortality benefit (NNT of 6 over 36 months) in heart failure 2
• MRAs are effective for resistant hypertension and can be combined with thiazide diuretics 1
• Monitor serum potassium and creatinine closely when combining MRA with ARB—do not use if creatinine ≥2.0 mg/dL (women) or ≥2.5 mg/dL (men), or if potassium ≥5.0 mEq/L 1

Drugs to Avoid

• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects and increased risk of worsening HF. 1
• Avoid alpha-blockers (doxazosin) as they increase HF risk 2.04-fold compared to thiazide diuretics. 1
• Avoid clonidine and moxonidine due to increased mortality in HF patients. 1
• Avoid direct renin inhibitors (aliskiren) when combined with ARBs due to increased adverse events. 1

Monitoring Requirements

• Assess renal function and electrolytes before initiating SGLT2i and beta-blocker, then periodically thereafter. 2
• Monitor for hypotension, particularly when uptitrating beta-blockers with existing ARB therapy 3
• Check standing BP to assess for orthostatic hypotension, especially in elderly patients 1
• Monitor potassium levels closely given combination of ARB and potential MRA use 3

Implementation Strategy

1. Add SGLT2 inhibitor immediately (empagliflozin 10mg or dapagliflozin 10mg daily) 1
2. Start beta-blocker at low dose (e.g., carvedilol 3.125mg twice daily, metoprolol succinate 25mg daily, or bisoprolol 2.5mg daily) 2
3. Uptitrate beta-blocker every 2 weeks as tolerated to target doses used in clinical trials 2
4. Reassess BP after 4 weeks—if still >130 mmHg systolic, add MRA 1
5. Continue valsartan but verify dose is ≤320mg daily 3

Common Pitfalls to Avoid

• Do not delay initiating multiple medication classes simultaneously—the evidence supports early combination therapy in high-risk patients 1, 2
• Do not restart amlodipine despite its efficacy—the documented peripheral edema will likely recur and worsen compliance 4
• Do not undertitrate beta-blockers—mortality benefits are seen at target doses, not low doses 2
• Do not add medications without checking renal function and electrolytes first—this patient is on an ARB and may need MRA, creating hyperkalemia risk 3