What medication is appropriate for treating both hypertension and pulmonary hypertension?

Calcium Channel Blockers Are the Only Medication Class Appropriate for Both Conditions—But Only in the Rare Vasoreactive PAH Patient

Calcium channel blockers (specifically long-acting nifedipine, diltiazem, or amlodipine) are the only antihypertensive medications that can appropriately treat both systemic hypertension and pulmonary arterial hypertension, but they should only be used in PAH patients who demonstrate acute vasoreactivity during right heart catheterization—approximately 10% of idiopathic PAH patients. 1, 2

Critical Prerequisite: Vasoreactivity Testing

• All patients with suspected PAH must undergo vasoreactivity testing during right heart catheterization before considering calcium channel blockers for PAH treatment 2
• Only patients demonstrating acute vasoreactivity (defined as a reduction in mean pulmonary arterial pressure ≥10 mmHg to reach an absolute value <40 mmHg with increased or unchanged cardiac output) are candidates for high-dose CCB therapy 1
• If vasoreactivity testing is positive, high-dose CCBs (long-acting nifedipine, diltiazem, or amlodipine) are recommended as first-line therapy for this small subset of patients 2

Specific CCB Recommendations

• Long-acting nifedipine, diltiazem, or amlodipine are the preferred agents 2
• Verapamil should be avoided due to negative inotropic effects 2
• Patients must be closely monitored, and if they do not improve to WHO functional class I or II, additional PAH-specific therapy must be added 2

Why Other Antihypertensives Are Contraindicated or Problematic

Absolutely Contraindicated:

• Nitrates and nitrate-like medications (including nicorandil) are absolutely contraindicated in PAH patients taking phosphodiesterase-5 inhibitors due to risk of profound systemic hypotension 3

Requiring Extreme Caution:

• Beta-blockers may worsen right ventricular function and exercise capacity in PAH patients 3
• ACE inhibitors and ARBs may cause excessive hypotension in PAH patients who are preload-dependent 3

The Reality for Non-Vasoreactive PAH Patients

For the vast majority (approximately 90%) of PAH patients who are non-vasoreactive 2:

• Initial oral combination therapy with ambrisentan and tadalafil is recommended as first-line treatment, as it has proven superior to monotherapy in delaying clinical failure 2, 4
• For high-risk (WHO functional class IV) patients, continuous intravenous epoprostenol should be prioritized as it has reduced 3-month mortality 2
• Traditional antihypertensive medications have no role in treating their PAH 3

Common Pitfall to Avoid

Do not empirically start CCBs for PAH without documented vasoreactivity testing. 3 Using CCBs in non-vasoreactive PAH patients is ineffective and delays appropriate PAH-specific therapy, potentially worsening outcomes. The European Respiratory Society explicitly states that CCBs should only be used in vasoreactive PAH patients 3

Managing Coexistent Systemic Hypertension in PAH Patients

If a PAH patient has coexistent systemic hypertension but is not vasoreactive:

• Avoid beta-blockers, ACE inhibitors/ARBs (due to preload dependence), and all nitrates 3
• Consider diuretics for volume management, particularly if signs of right ventricular failure are present 3, 2
• Consult with a pulmonary hypertension specialist before initiating any antihypertensive therapy 5