What are the medical interventions for hypertension and heart failure?

Medical Interventions for Hypertension and Heart Failure

Pharmacological Treatment for Hypertension

For hypertension management, initiate treatment with a combination of thiazide or thiazide-like diuretics, ACE inhibitors (or ARBs), and calcium channel blockers, targeting blood pressure <130/80 mmHg in most patients. 1, 2

First-Line Antihypertensive Agents

• Thiazide or thiazide-like diuretics (hydrochlorothiazide or chlorthalidone) are recommended as foundational therapy 2
• ACE inhibitors (such as lisinopril or enalapril) or ARBs (such as candesartan) should be included in the initial regimen 3, 2
• Calcium channel blockers (such as amlodipine) complete the triple therapy approach 2
• These three drug classes should be titrated according to office and home blood pressure measurements to achieve target levels 2

Blood Pressure Targets

• Target BP <130/80 mmHg for adults under 65 years 1, 2
• Target BP <130 mmHg systolic for adults 65 years and older 2
• Home blood pressure monitoring should target <135/85 mmHg 1, 4

Resistant Hypertension Management

When blood pressure remains uncontrolled on three appropriately dosed medications including a diuretic, add spironolactone 25-50 mg daily as the preferred fourth-line agent. 5, 6

• Start spironolactone at 25 mg daily and monitor serum potassium and renal function within 1-2 weeks 5
• Eplerenone serves as an alternative mineralocorticoid receptor antagonist if spironolactone causes gynecomastia 5
• Confirm true treatment resistance with 24-hour ambulatory BP monitoring or home BP monitoring before escalating therapy 5
• Verify medication adherence, as non-adherence affects 10-80% of hypertensive patients and represents the most common cause of apparent treatment resistance 5

Pharmacological Treatment for Heart Failure

For heart failure with reduced ejection fraction (HFrEF), combine diuretics, ACE inhibitors (or ARBs), beta-blockers, and aldosterone receptor antagonists, as these drugs both lower blood pressure and improve heart failure outcomes. 7, 6

Core Heart Failure Medications

• Diuretics (thiazides for BP control; loop diuretics for severe HF or renal impairment) manage volume overload 7
• ACE inhibitors or ARBs (candesartan or valsartan show equivalent benefit) are essential for neurohormonal blockade 7
• Beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol) have proven mortality benefit 7
• Aldosterone receptor antagonists (spironolactone or eplerenone) reduce mortality in NYHA Class III-IV heart failure 7, 6

Blood Pressure Targets in Heart Failure

Target BP <130/80 mmHg in heart failure patients, with consideration for lowering to <120/80 mmHg in selected cases. 7

• Lower blood pressure slowly in patients with elevated diastolic BP who have coronary disease and myocardial ischemia 7
• Exercise caution when diastolic BP falls below 60 mmHg, particularly in diabetic patients or those over 60 years old 7
• In older patients with wide pulse pressures, monitor carefully for signs of myocardial ischemia or worsening heart failure when systolic BP is lowered 7

Additional Considerations for Heart Failure

• Hydralazine/isosorbide dinitrate should be added to standard therapy in Black patients with NYHA Class III-IV heart failure 7
• SGLT2 inhibitors provide beneficial BP-lowering effects that improve cardiac afterload, ventricular-arterial coupling, and cardiac remodeling 8

Drugs to Avoid in Heart Failure

• Nondihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided due to negative inotropic effects 7
• Clonidine and moxonidine are contraindicated, as moxonidine increased mortality in heart failure trials 7
• Alpha-blockers (such as doxazosin) should only be used if other agents at maximum tolerated doses fail to control BP, as doxazosin increased heart failure risk 2-fold in the ALLHAT trial 7

Lifestyle Modifications

Sodium restriction to <2.3 g/day represents the most impactful lifestyle modification, producing an additional 10-20 mmHg BP reduction in resistant hypertension. 1, 5

Evidence-Based Lifestyle Interventions

• DASH diet (high in fruits, vegetables, low-fat dairy, whole grains) effectively reduces blood pressure and prevents heart failure 7
• Regular aerobic exercise of 150 minutes moderate-intensity weekly lowers blood pressure effectively 1, 5
• Weight loss should be pursued in patients with BMI >25, providing additive BP reduction 1, 5
• Potassium supplementation enhances BP control 7
• Alcohol moderation or abstinence is recommended 7

Lifestyle Modifications Specific to Heart Failure

• Exercise training is safe and effective for NYHA Class I-III heart failure patients to improve functional status 7
• Sodium restriction reduces congestive symptoms in symptomatic heart failure 7
• Mediterranean diet (emphasizing olive oil, vegetables, fruits, whole grains, legumes, fish, nuts) prevents cardiovascular events 7

Patient Engagement Strategies

• Motivational interviewing increases adherence to treatment and lifestyle modifications 1
• Home blood pressure monitoring improves diagnosis acceptance, patient empowerment, and treatment adherence 1
• Single-pill combinations reduce therapy complexity and improve adherence 1

Treatment Intensification Timeline

• Reassess within 2-4 weeks after each treatment adjustment 1
• Achieve target blood pressure within 3 months 1
• Avoid delaying treatment intensification in stage 2 hypertension (≥160/100 mmHg), as this increases cardiovascular risk 1

When to Refer to Specialist

• Multiple drug intolerances 5, 4
• Suspected secondary hypertension 1, 5
• Blood pressure remaining uncontrolled despite optimal therapy 4

Critical Pitfalls to Avoid

• Never assume treatment failure without first confirming medication adherence and ruling out secondary causes 1
• Avoid short-acting nifedipine for hypertensive urgencies due to risk of precipitous BP drops 4
• Do not reduce blood pressure by more than 25% in the first hour during hypertensive urgency, as this may precipitate organ ischemia 4
• Avoid monotherapy in high-risk patients with multiple comorbidities 4

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