What are the guidelines for managing hypertension in a patient with a history of cardiovascular disease or kidney disease?

Hypertension Management in Patients with Cardiovascular Disease or Chronic Kidney Disease

For patients with cardiovascular disease or chronic kidney disease, initiate antihypertensive drug therapy immediately at blood pressure ≥130/80 mm Hg with a target of <130/80 mm Hg, using ACE inhibitors or ARBs as first-line agents for those with CKD or diabetes with albuminuria, and beta-blockers for those with coronary artery disease or heart failure. 1, 2

Blood Pressure Thresholds and Targets

When to Start Treatment

• Immediate pharmacotherapy is indicated when confirmed BP is ≥130/80 mm Hg in patients with existing cardiovascular disease, chronic kidney disease, diabetes, or 10-year ASCVD risk ≥10% 1
• For patients with CKD or diabetes, the target BP is <130/80 mm Hg, which is lower than the standard <140/90 mm Hg goal for uncomplicated hypertension 3, 2
• In dialysis patients specifically, target predialysis BP of 140/90 mm Hg (measured sitting) is reasonable, provided there is no substantial orthostatic or intradialytic hypotension 3

Target Blood Pressure Goals

• Cardiovascular disease patients: <140/90 mm Hg, with consideration for <130/80 mm Hg if tolerated 3, 1
• Chronic kidney disease: <130/80 mm Hg for maximum renal protection, particularly with proteinuria >1 g/24 hours where 125/75 mm Hg provides optimal benefit 3
• Diabetes with albuminuria: <130/80 mm Hg 3, 2
• Post-stroke/TIA: <140/90 mm Hg 3

First-Line Medication Selection by Comorbidity

Chronic Kidney Disease

• ACE inhibitors or ARBs are the preferred first-line agents for all patients with CKD, regardless of diabetes status 3, 2
• Use ARB if ACE inhibitor is not tolerated 3
• These agents provide renal protection beyond blood pressure lowering, particularly in patients with albuminuria 1
• Monitor potassium and creatinine within 7-14 days after initiation 1

Cardiovascular Disease Subtypes

Stable ischemic heart disease/Post-MI:

• Beta-blockers (guideline-directed medical therapy: carvedilol, metoprolol succinate, or bisoprolol) are first-line 3
• Add ACE inhibitor or ARB for additional BP control 3
• For angina specifically, add dihydropyridine calcium channel blockers if beta-blockers alone are insufficient 3

Heart failure with reduced ejection fraction:

• Beta-blockers (GDMT) as first-line 3
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 3

Heart failure with preserved ejection fraction:

• Diuretics for volume overload 3
• Add ACE inhibitor or ARB and beta-blocker for incremental BP control 3
• Consider angiotensin receptor-neprilysin inhibitor and mineralocorticoid receptor antagonists 3

Atrial fibrillation:

• ARBs are favored as they may reduce AF recurrence 3

Aortic disease:

• Beta-blockers are preferred for patients with thoracic aorta disease 3, 1

Secondary stroke prevention:

• Thiazide diuretic, ACE inhibitor, ARB, or thiazide + ACE inhibitor combination 3
• If previously treated, restart drugs a few days post-event 3
• If not previously treated, start drug treatment a few days post-event if BP ≥140/90 mm Hg 3

Monotherapy vs. Combination Therapy

Stage 1 Hypertension (130-139/80-89 mm Hg in high-risk patients)

• Start with monotherapy using the comorbidity-specific agent listed above 1, 2
• For CKD: ACE inhibitor or ARB 3, 1
• For CAD: Beta-blocker 3

Stage 2 Hypertension (≥140/90 mm Hg) or BP ≥20/10 mm Hg Above Target

• Initiate two-drug combination therapy immediately 3, 1, 2
• Typical combinations include the comorbidity-specific agent plus a thiazide-type diuretic 3, 2
• For CKD patients: ACE inhibitor/ARB + thiazide diuretic (use with caution if eGFR <30 mL/min/1.73m²) 3
• For CAD patients: Beta-blocker + ACE inhibitor/ARB or + dihydropyridine calcium channel blocker 3

Essential Lifestyle Modifications

All patients require intensive lifestyle interventions regardless of medication use 3:

• Sodium restriction: <1500 mg/day or at minimum a reduction of ≥1000 mg/day 3
• Potassium supplementation: 3500-5000 mg/day through dietary sources 3
• Weight loss: Target ideal body weight or minimum 1 kg reduction if overweight/obese 3
• Physical activity: Aerobic or dynamic resistance exercise 90-150 min/week, or isometric resistance 3 sessions/week 3
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 3
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat 3, 2

Monitoring Schedule

• Monthly follow-up after initiation or dose changes until BP target is achieved 3, 1
• Assess adherence and response to treatment at each visit 1
• Monitor potassium and creatinine within 7-14 days when starting ACE inhibitors or ARBs, particularly critical in CKD patients 1
• Once controlled, patients with CVD or CKD should have BP rechecked every 3-6 months 3

Critical Pitfalls to Avoid

• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in heart failure with reduced ejection fraction 3
• Avoid beta-blockers in aortic insufficiency as they slow heart rate inappropriately 3
• Use ACE inhibitors with caution in post-kidney transplant patients; calcium channel blockers are preferred in the first month post-transplant to avoid hypotension-induced graft thrombosis 3
• In dialysis patients with resistant hypertension uncontrolled on three agents including minoxidil, evaluate for secondary causes before considering nephrectomy 3
• Do not delay pharmacotherapy in high-risk patients (CVD, CKD, diabetes) even with Stage 1 hypertension; lifestyle modifications alone are insufficient 3, 1