What is the best supportive treatment for congestion in patients with Hypertension (HTN)?

From the Guidelines

For patients with hypertension (HTN) and congestion, loop diuretics such as furosemide are the preferred initial treatment to reduce fluid retention and alleviate congestion. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, loop diuretics are the preferred diuretic agents for use in most patients with heart failure, which can be applicable to patients with HTN and congestion. The treatment goal is to eliminate clinical evidence of fluid retention using the lowest dose possible to maintain euvolemia.

Some key points to consider when treating congestion in HTN patients include:

• Using diuretics such as furosemide (20-40 mg once or twice daily) to reduce fluid retention and alleviate congestion
• Considering the addition of thiazide diuretics like chlorthalidone or hydrochlorothiazide for patients with mild fluid retention
• Monitoring for electrolyte imbalances, particularly potassium levels, when using diuretics
• Elevating the head while sleeping and moderate physical activity to help mobilize fluid
• Seeking immediate medical attention if congestion is accompanied by shortness of breath or worsening symptoms, as this could indicate worsening heart failure requiring more intensive intervention.

It's essential to note that diuretics should not be used in isolation but always combined with other guideline-directed medical therapy (GDMT) for heart failure that reduces hospitalizations and prolongs survival, as the effects of diuretics on morbidity and mortality are uncertain 1.

From the Research

Best Supportive Treatment for Congestion in Hypertension

The best supportive treatment for congestion in hypertension is not explicitly stated in the provided studies. However, the studies suggest the following treatments for hypertension:

• Lifestyle modifications, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 2
• First-line drug therapy, including thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 2, 3
• Combination therapy, including combination of two or more agents from different pharmacologic classes, such as diuretics and potassium-sparing diuretics, beta blockers and diuretics, angiotensin-converting enzyme inhibitors and diuretics, angiotensin-II antagonists and diuretics, and calcium channel blockers and ACE inhibitors 4, 3

Key Points to Consider

• The choice of treatment should be based on the level of blood pressure and the presence of high atherosclerotic cardiovascular disease risk 2
• The goal of treatment is to achieve a blood pressure target of less than 130/80 mm Hg for adults under 65 years and less than 130 mm Hg for adults 65 years and older 2
• Combination therapy may be necessary to achieve adequate blood pressure control, especially in patients with chronic kidney disease and proteinuria, or heart failure with reduced ejection fraction 4

Treatment Options

• Thiazide diuretics, such as hydrochlorothiazide or chlorthalidone, are commonly used as first-line therapy for hypertension 2, 3
• Angiotensin-converting enzyme inhibitors, such as enalapril, or angiotensin receptor blockers, such as candesartan, are also commonly used as first-line therapy for hypertension 2, 3
• Calcium channel blockers, such as amlodipine, may be used as first-line therapy for hypertension, especially in patients with certain comorbidities, such as diabetes or chronic kidney disease 2, 5