What is the best treatment approach for a patient with stable angina and hypertension?

Treatment of Hypertension with Stable Angina

Patients with hypertension and stable angina should be treated with a β-blocker, an ACE inhibitor or ARB, and a thiazide or thiazide-like diuretic as the foundational regimen. 1

First-Line Pharmacological Regimen

The core treatment strategy consists of three medication classes used in combination:

β-Blockers

• β-blockers are the cornerstone of therapy and should be initiated first, particularly in patients with prior myocardial infarction (Class I; Level of Evidence A) 1
• They reduce myocardial oxygen demand by decreasing heart rate, contractility, and blood pressure, thereby reducing ischemic burden 2
• In patients without prior MI, β-blockers remain strongly recommended (Class I; Level of Evidence B) 1
• Cardioselective (β1) agents without intrinsic sympathomimetic activity are preferred 1
• Common pitfall: β-blockers should not be combined with nondihydropyridine calcium channel blockers (diltiazem or verapamil) due to increased risk of significant bradyarrhythmias and heart failure 1

ACE Inhibitors or ARBs

• ACE inhibitors are mandatory if the patient has prior MI, left ventricular systolic dysfunction, diabetes mellitus, or chronic kidney disease (Class I; Level of Evidence A) 1
• ACE inhibitors reduce cardiovascular death, MI, and stroke in patients with vascular disease 1
• ARBs are equally effective alternatives for patients intolerant of ACE inhibitors (Class I; Level of Evidence A) 1
• The combination of ACE inhibitors and ARBs should be avoided as it provides no additive benefit but increases adverse effects 1

Thiazide or Thiazide-Like Diuretics

• Thiazide diuretics are essential components of the regimen (Class I; Level of Evidence A) 1
• They reduce cardiovascular events as demonstrated in major trials including ALLHAT and SHEP 1
• These agents are as effective in secondary prevention as in primary prevention of cardiovascular events 1

When β-Blockers Are Contraindicated or Not Tolerated

Nondihydropyridine Calcium Channel Blockers

• If β-blockers cause unacceptable side effects or are contraindicated, substitute with a nondihydropyridine CCB (diltiazem or verapamil) (Class IIa; Level of Evidence B) 1
• Critical contraindication: Do not use nondihydropyridine CCBs if left ventricular dysfunction is present 1
• Do not use in patients with sinus bradycardia or greater than first-degree AV block 3

Add-On Therapy for Inadequate Control

Long-Acting Dihydropyridine Calcium Channel Blockers

• If angina or hypertension remains uncontrolled on the basic three-drug regimen, add a long-acting dihydropyridine CCB such as amlodipine (Class IIa; Level of Evidence B) 1
• Amlodipine is FDA-approved for both hypertension and chronic stable angina and can reduce the risk of hospitalization for angina and coronary revascularization procedures 4
• Long-acting dihydropyridines do not carry the same cardiac conduction risks as nondihydropyridines 3

Long-Acting Nitrates

• Long-acting nitrates or CCBs can be prescribed for symptom relief when β-blockers are contraindicated or cause unacceptable side effects (Class I; Level of Evidence B) 1
• Long-acting nitrates in combination with β-blockers should be prescribed when initial β-blocker therapy is unsuccessful (Class I; Level of Evidence B) 1
• Important limitation: Nitrates require a nitrate-free interval to avoid tolerance development and do not effectively treat hypertension 1
• Nitrates must not be used with phosphodiesterase inhibitors (sildenafil-type drugs) 1

Blood Pressure Targets

• Target blood pressure is <140/90 mmHg for patients with stable angina (Class I; Level of Evidence A) 1
• A lower target of <130/80 mmHg may be considered in selected individuals with CAD, previous stroke/TIA, or CAD risk equivalents (Class IIb; Level of Evidence B) 1
• Caution with diastolic pressure: In patients with CAD, lower blood pressure slowly and avoid inducing diastolic blood pressure below 60 mmHg, especially in diabetic patients or those over age 60 1

Essential Adjunctive Therapies

Antiplatelet Therapy

• Aspirin 75-325 mg daily is mandatory unless contraindications exist (Class I; Level of Evidence A) 1
• Clopidogrel should be reserved for patients who cannot take aspirin 1

Lipid-Lowering Therapy

• Statin therapy should be initiated even with mild LDL cholesterol elevations, as it decreases the risk of adverse ischemic events in established CAD (Class I; Level of Evidence A) 1

Sublingual Nitroglycerin

• All patients should have sublingual nitroglycerin or nitroglycerin spray available for immediate relief of acute anginal episodes 1

Special Considerations for Severe Uncontrolled Hypertension

• In patients with uncontrolled severe hypertension taking antiplatelet or anticoagulant drugs, blood pressure should be lowered without delay to reduce the risk of hemorrhagic stroke 1

Algorithm Summary

1. Start with β-blocker + ACE inhibitor (or ARB if intolerant) + thiazide diuretic 1
2. If β-blocker contraindicated: Substitute nondihydropyridine CCB (if no LV dysfunction) 1
3. If symptoms persist: Add long-acting dihydropyridine CCB 1
4. Always include: Aspirin, statin, sublingual nitroglycerin 1
5. Monitor: Avoid excessive diastolic lowering (<60 mmHg) 1