What antihypertensive should be started in a patient with systemic hypertension, heart failure with preserved ejection fraction (EF), shortness of breath, chest pain, and acute kidney injury (AKI) with a blood pressure of 150/90 mmHg?

Antihypertensive Management in HFpEF with AKI

Start with a loop diuretic (furosemide) to address volume overload and congestion, which is the immediate priority in this symptomatic patient with shortness of breath. 1

Immediate Management: Diuretic Therapy

• Loop diuretics are the cornerstone initial therapy for patients with HFpEF presenting with signs and symptoms of congestion (shortness of breath), as they improve symptoms and exercise capacity. 1
• Furosemide should be initiated at 20-80 mg as a single dose, with careful titration based on diuretic response and monitoring of renal function given the concurrent AKI. 2
• The presence of AKI requires cautious dosing but does not contraindicate diuretic use when volume overload is present—in fact, uncontrolled hypertension with edema and pulmonary congestion are indications for aggressive diuresis. 3

Blood Pressure Control Strategy

First-Line Agents for Long-Term Management

Once volume status is optimized and the patient is stabilized:

• ACE inhibitors or ARBs should be initiated as they are recommended for hypertension treatment in HFpEF and have proven cardiovascular benefits. 1, 4
• Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) should be added, particularly given the chest pain suggesting possible coronary artery disease, as they reduce myocardial oxygen demand. 4, 5
• These agents work synergistically to control blood pressure while addressing the underlying heart failure pathophysiology. 6, 7

Additional Considerations for Resistant Hypertension

• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) should be considered if blood pressure remains uncontrolled, though potassium and renal function must be monitored closely given the AKI. 1, 4
• Long-acting dihydropyridine calcium channel blockers (amlodipine) can be added as safe adjunctive therapy if blood pressure targets are not met with first-line agents. 5, 8

Critical Medications to AVOID

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are contraindicated as they increase the risk of heart failure worsening and hospitalization due to negative inotropic effects. 1, 4, 5
• Hydralazine monotherapy is explicitly classified as Class III Harm in heart failure patients and should not be used. 5
• Avoid combining ACE inhibitors with ARBs and MRAs due to increased risk of renal dysfunction and hyperkalemia, particularly dangerous in this patient with existing AKI. 1

Blood Pressure Target

• Target blood pressure should be <130/80 mmHg if tolerated, though a J-shaped relationship exists in HFpEF with lowest cardiovascular risk at systolic BP 120-130 mmHg. 4, 9
• The current BP of 150/90 mmHg requires treatment, but avoid overly aggressive reduction that could worsen renal perfusion in the setting of AKI. 9

Monitoring Requirements

• Monitor serum potassium and renal function closely, especially when initiating ACE inhibitors/ARBs with potential future addition of MRAs. 4
• Assess for orthostatic hypotension and signs of worsening heart failure with each medication adjustment. 4
• Track urine output and daily weights to guide diuretic dosing and assess volume status. 2

Clinical Pitfalls to Avoid

• Do not withhold diuretics due to AKI if the patient has volume overload—congestion itself worsens renal function (cardiorenal syndrome). 3
• Hypertension prevalence in AKI is approximately 70%, with post-renal causes having the highest rates (85%), so investigate for obstructive uropathy if not already done. 3
• The elevated pulse pressure (60 mmHg) suggests increased arterial stiffness, which independently increases cardiovascular risk in HFpEF regardless of systolic BP control. 9