From the Guidelines
For a patient with hypertension (HTN), heart failure (HF), and atrial fibrillation (AFib) who is allergic to beta blockers, an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) combined with a diuretic would be the best choice, as these medications have been shown to improve outcomes in HF and lower blood pressure 1. When considering the management of HTN in patients with HF, it's crucial to prioritize medications that not only control blood pressure but also have a beneficial effect on heart failure outcomes.
- The use of ACE inhibitors or ARBs is recommended as they have been shown to improve outcomes for patients with HF and lower BP 1.
- Diuretics, particularly thiazide diuretics, are also recommended for BP control and to reverse volume overload and associated symptoms in HF patients 1.
- Given the patient's allergy to beta blockers, alternative rate control agents for AFib, such as digoxin, may be considered, but the primary focus should be on managing HTN and HF with the aforementioned medications.
- It's essential to avoid certain medications in patients with HF and hypertension, such as nondihydropyridine CCBs (like verapamil and diltiazem), clonidine, and moxonidine, due to their potential to worsen HF 1. The target blood pressure should be less than 130/80 mm Hg, with consideration for lowering it further to less than 120/80 mm Hg, while being cautious of inducing too low diastolic blood pressure, especially in older patients or those with diabetes mellitus 1.
- Regular monitoring of blood pressure, heart rate, renal function, and electrolytes is crucial when initiating these medications, with dose adjustments as needed based on patient response and tolerance.
From the FDA Drug Label
INDICATIONS AND USAGE Digoxin is indicated for the treatment of mild to moderate heart failure.
Digoxin increases left ventricular ejection fraction and improves heart failure symptoms as evidenced by exercise capacity and heart failure symptoms as evidenced by exercise capacity and heart failure-related hospitalizations and emergency care, while having no effect on mortality. Where possible, digoxin should be used with a diuretic and an angiotensin-converting enzyme inhibitor, but an optimal order for starting these three drugs cannot be specified. Heart Failure: Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation.
- Digoxin may be considered for the treatment of heart failure (HF) and atrial fibrillation (AFib) in patients allergic to beta blockers.
- It is essential to use digoxin with a diuretic and an angiotensin-converting enzyme inhibitor when possible.
- Lisinopril, an angiotensin-converting enzyme inhibitor, can be used to treat heart failure and hypertension.
- The combination of lisinopril, digitalis, and diuretics can reduce signs and symptoms of heart failure.
- However, the choice between digoxin and lisinopril depends on individual patient needs and medical history 2 3.
From the Research
Hypertension Medications for Heart Failure and Atrial Fibrillation
Given the allergy to beta blockers, alternative hypertension medications must be considered for patients with heart failure (HF) and atrial fibrillation (AF).
- Angiotensin-converting-enzyme (ACE) inhibitors have been shown to be beneficial in patients with HF and AF, as they can help prevent the development or recurrence of AF 4.
- Angiotensin receptor blockers (ARBs) may also be a suitable option, as they have been associated with a reduced risk of AF compared to beta blockers and diuretics 5.
- The CAN-TREAT HFrEF + AF algorithm proposes the use of renin-angiotensin-aldosterone modification, which includes ACE inhibitors and ARBs, as part of the initial management of newly discovered concomitant HF and AF 6.
Non-Pharmacological Management
In addition to pharmacological management, non-pharmacological approaches such as catheter ablation may be considered for patients with HF and AF, as they have been shown to improve survival, quality of life, and ventricular function, and reduce HF hospitalizations 7.
Blood Pressure Management
Achieving blood pressure goals is crucial in preventing HF and other cardiovascular diseases, and using evidence-based treatments can improve clinical outcomes for patients with comorbid hypertension and HF 8.
- ACE inhibitors and ARBs can help control blood pressure and reduce the risk of AF, making them a potential first-line treatment option for patients with HF and AF who are allergic to beta blockers.