What is the optimal management strategy for a patient with hypertension and coronary artery disease?

Optimal Management of Hypertension in Coronary Artery Disease

For patients with hypertension and coronary artery disease, initiate treatment with an ACE inhibitor or ARB as foundational therapy, combined with a beta-blocker (especially if post-MI or with angina), and target blood pressure to <130/80 mmHg, with consideration for even lower targets (120-129 mmHg systolic) if well tolerated. 1, 2

Blood Pressure Targets

• Target BP <130/80 mmHg for all patients with hypertension and CAD 1
• The 2024 ESC guidelines recommend targeting systolic BP of 120-129 mmHg in most adults if treatment is well tolerated, which is particularly appropriate for patients with established CAD 1, 2
• For patients with left ventricular dysfunction, consider an even more aggressive target of <120/80 mmHg 1, 3
• In older patients (≥65 years), target systolic BP of 130-139 mmHg is recommended 1
• Avoid lowering diastolic BP below 60 mmHg in patients with CAD, as this may worsen myocardial ischemia 1

First-Line Pharmacologic Therapy

Primary Agents (Start Here)

ACE Inhibitors or ARBs:

• These are the cornerstone of therapy for hypertension with CAD and should be initiated first 1, 2
• They provide cardiovascular protection beyond blood pressure lowering alone 2
• Recommended starting dose for losartan: 50 mg once daily, can increase to 100 mg daily 4
• Monitor serum creatinine, eGFR, and potassium at baseline and annually 2
• Never combine an ACE inhibitor with an ARB - this increases adverse events without additional benefit 2

Beta-Blockers:

• Add a beta-blocker if the patient has: 1, 5
  • History of prior myocardial infarction
  • Active angina pectoris
  • Heart failure with reduced ejection fraction
• Metoprolol is a commonly used agent; avoid abrupt discontinuation in CAD patients as this can precipitate severe angina, MI, or ventricular arrhythmias 5
• Beta-blockers are NOT recommended as first-line monotherapy for uncomplicated hypertension without these specific indications 2

Combination Therapy Algorithm

If BP remains ≥140/90 mmHg on ACE inhibitor/ARB:

• Add a thiazide-like diuretic (chlorthalidone or indapamide preferred) OR a dihydropyridine calcium channel blocker 1
• Use single-pill combination formulations whenever possible to improve adherence 2

If BP remains ≥160/100 mmHg at presentation:

• Initiate combination therapy immediately with two drugs: ACE inhibitor/ARB plus either thiazide-like diuretic or dihydropyridine CCB 1, 2

If BP not controlled on three-drug combination:

• Add spironolactone (mineralocorticoid receptor antagonist) as the fourth agent 1
• If spironolactone not tolerated, consider eplerenone 1
• Alternative fourth-line agents include: centrally acting agents, alpha-blockers, or hydralazine 1

Specific Drug Considerations

Calcium Channel Blockers:

• Use long-acting dihydropyridine CCBs (amlodipine, nifedipine) if additional BP lowering needed 1, 3
• Avoid combining beta-blockers with non-dihydropyridine CCBs (diltiazem, verapamil) due to risk of bradyarrhythmias and heart failure 1
• Non-dihydropyridine CCBs can substitute for beta-blockers only if beta-blockers are contraindicated AND there is no left ventricular dysfunction 1

Diuretics:

• Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide for cardiovascular event reduction 1
• Loop diuretics should be reserved for patients with NYHA Class III-IV heart failure or eGFR <30 mL/min 6

Essential Lifestyle Modifications

These must be implemented concurrently with pharmacotherapy: 1

• Exercise: Minimum 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) plus resistance training 2-3 times/week 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Dietary modifications: 1
  • Increase vegetables, fresh fruits, fish, nuts, unsaturated fatty acids
  • Reduce red meat consumption
  • Low-fat dairy products
• Sodium restriction: <2000 mg/day 7
• Alcohol limitation: <14 units/week for men, <8 units/week for women (preferably avoid entirely) 1
• Smoking cessation: Mandatory 1

Critical Monitoring Parameters

Initial follow-up (1-3 months): 7

• Reassess BP to ensure target <130/80 mmHg is achieved
• Evaluate medication adherence and tolerability
• Check serum creatinine, eGFR, and potassium if on ACE inhibitor/ARB

Ongoing monitoring: 7

• Continue BP monitoring and reassess cardiovascular risk factors annually
• Monitor for adverse effects including hypotension, bradycardia, hyperkalemia, and renal dysfunction

Common Pitfalls to Avoid

• Do not abruptly discontinue beta-blockers in patients with CAD - taper over 1-2 weeks to avoid rebound ischemia 5
• Poor medication adherence is the most common cause of resistant hypertension - use once-daily dosing and single-pill combinations 2
• Avoid excessive diastolic BP lowering (<60 mmHg) as this may worsen coronary perfusion 1
• Do not use beta-blockers alone in pheochromocytoma without prior alpha-blockade 5
• Hypertension remains a major cardiovascular risk factor requiring treatment to target even in patients with otherwise low risk (e.g., zero coronary calcium score) 7
• Device-based therapies (renal denervation) are not recommended for routine treatment outside of clinical trials 1