What is the recommended treatment for a patient with hypertensive heart failure?

Treatment of Hypertensive Heart Failure

For patients with hypertensive heart failure, initiate guideline-directed medical therapy (GDMT) consisting of an ACE inhibitor (or ARB if intolerant), a beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), a mineralocorticoid receptor antagonist, and diuretics as needed for congestion, targeting a blood pressure <130/80 mmHg. 1, 2

Initial Pharmacologic Approach

Core Triple Therapy Foundation

• Start ACE inhibitor or ARB immediately as first-line therapy to reduce mortality, hospitalization, and blood pressure in all patients with symptomatic heart failure, regardless of ejection fraction 1, 2, 3

  • ACE inhibitors remain the preferred first choice for renin-angiotensin system inhibition 1
  • ARBs (candesartan or valsartan) are reasonable alternatives if ACE inhibitor causes cough or angioedema 1, 2
  • Lisinopril demonstrates superior blood pressure reduction compared to hydrochlorothiazide and equivalent efficacy to beta-blockers 3

• Add beta-blocker concurrently (not sequentially) using only carvedilol, metoprolol succinate, or bisoprolol, which have proven mortality benefit 1, 2

  • Carvedilol may be preferred in refractory hypertension due to combined α1-β1-β2-blocking properties 2
  • These agents reduce risk of heart failure hospitalization and death when combined with ACE inhibitors 1

• Incorporate mineralocorticoid receptor antagonist (spironolactone or eplerenone) once initial regimen is established for additional mortality benefit and blood pressure control 1, 2

  • Recommended for patients who remain symptomatic despite ACE inhibitor and beta-blocker therapy 1
  • Monitor potassium and renal function closely to avoid hyperkalemia 1

Diuretic Management

• Use diuretics to control volume overload and improve symptoms, selecting agent based on severity 1, 2
  • Thiazide diuretics for blood pressure control and mild volume overload 1, 2
  • Loop diuretics for severe heart failure or significant renal impairment 1, 2
  • Diuretics improve symptoms and exercise capacity in patients with congestion 1

Advanced Therapy Considerations

ARNI Therapy

• Consider sacubitril/valsartan as replacement for ACE inhibitor in ambulatory patients with HFrEF who remain symptomatic despite optimal triple therapy to further reduce hospitalization and death 1

SGLT2 Inhibitors

• Add SGLT2 inhibitor for symptomatic heart failure patients, which provides modest blood pressure-lowering effects and improves outcomes in both HFrEF and HFpEF 2, 4, 5

Race-Specific Therapy

• For Black patients with NYHA Class III or IV heart failure, add hydralazine/isosorbide dinitrate to the regimen of diuretic, ACE inhibitor/ARB, and beta-blocker for mortality reduction 2
• For non-Black patients with refractory hypertension, hydralazine/isosorbide dinitrate may be considered for additional blood pressure control 2

Blood Pressure Targets

• Primary target: systolic BP <130 mmHg and diastolic BP <80 mmHg 1, 2
• Consider lowering systolic BP further to <120 mmHg if tolerated, as successful heart failure trials achieved systolic BP in the 110-130 mmHg range 2
• Avoid lowering diastolic BP below 60 mmHg in patients with coronary artery disease, diabetes, or age >60 years to prevent worsening myocardial ischemia 2
• Standard heart failure treatment typically lowers systolic BP to 110-130 mmHg, so optimizing heart failure therapy generally achieves adequate blood pressure control 2

Critical Medications to AVOID

Absolute Contraindications

• Never use nondihydropyridine calcium channel blockers (verapamil, diltiazem) as they have negative inotropic effects, increase risk of heart failure worsening and hospitalization 1, 2

• Avoid alpha-blockers (doxazosin) due to increased risk of developing heart failure 2

• Do not use clonidine or moxonidine, as moxonidine increases mortality in heart failure patients 2

Combination Therapy Warnings

• Do not combine ARB with both ACE inhibitor and mineralocorticoid receptor antagonist (triple renin-angiotensin system blockade) due to increased risk of renal dysfunction and hyperkalemia 1

Treatment Algorithm by Ejection Fraction

Heart Failure with Reduced Ejection Fraction (HFrEF)

1. Initiate simultaneously: ACE inhibitor (or ARB) + beta-blocker + diuretic (thiazide for mild volume overload, loop for severe HF/renal impairment) 2
2. Add mineralocorticoid receptor antagonist once initial regimen established 1, 2
3. Titrate to maximum tolerated doses targeting BP <130/80 mmHg 1, 2
4. Consider sacubitril/valsartan replacement for ACE inhibitor if symptomatic despite optimal therapy 1
5. Add SGLT2 inhibitor for additional benefit 2, 4, 5
6. If BP remains elevated, consider hydralazine/isosorbide dinitrate or dihydropyridine calcium channel blocker 2

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Use diuretics for volume overload symptoms to control hypertension 1
• Prescribe ACE inhibitors or ARBs and beta-blockers after managing volume overload, titrating to achieve systolic BP <130 mmHg 1
• Add SGLT2 inhibitor for proven benefit in HFpEF 2, 4, 5
• The principal drug treatment appears the same regardless of ejection fraction, directed by symptoms, signs, severity, and concomitant conditions 4, 5

Non-Pharmacologic Management

• Restrict sodium intake to approximately 2g per day as essential component of treatment 2
• Implement closely monitored exercise program with moderate-intensity aerobic exercise ≥150 minutes per week plus resistance training 2-3 times weekly 2
• Achieve weight reduction targeting BMI 20-25 kg/m² for overweight or obese patients 2
• Advise alcohol moderation or complete avoidance 2

Monitoring Requirements

• Assess renal function and electrolytes regularly, especially after initiating or titrating ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2
• Perform echocardiography to assess left ventricular ejection fraction for appropriate therapy selection and to evaluate for hypertension-mediated organ damage 1
• Consider ambulatory blood pressure monitoring to ensure adequate 24-hour BP control 2

Common Pitfalls to Avoid

• Do not delay beta-blocker initiation until after ACE inhibitor titration; start both simultaneously 2
• Avoid excessive blood pressure lowering that compromises organ perfusion, particularly diastolic BP <60 mmHg in high-risk patients 2
• Do not use ARB before beta-blocker in patients already taking ACE inhibitor 1
• Recognize that treatment of hypertension prevents or delays onset of heart failure and prolongs life, making aggressive BP control essential 1
• Remember that all drugs decreasing heart failure endpoints also lower blood pressure, so focus on optimizing heart failure therapy rather than adding additional antihypertensives 4, 5