What is the best approach to manage hypertension in an elderly patient with Congestive Heart Failure (CHF) on Entresto (sacubitril and valsartan), labetalol, hydralazine, and Torsemide?

Management of Uncontrolled Hypertension in Elderly CHF Patient on Entresto

Direct Recommendation

Optimize the current diuretic regimen by switching from torsemide 20mg to chlorthalidone 12.5-25mg daily, as thiazide-like diuretics provide superior blood pressure control compared to loop diuretics in heart failure patients with hypertension. 1

Current Medication Assessment

Your patient is on guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF), but the blood pressure remains uncontrolled at 160s mmHg systolic. 1

• Entresto 49-51mg provides combined neprilysin inhibition and angiotensin receptor blockade—this is appropriate and should be continued 2
• Labetalol 100mg TID provides beta-blockade, though carvedilol would be preferred for HFrEF due to superior blood pressure reduction through combined α1-β1-β2 blockade 1
• Hydralazine 50mg TID is appropriate, especially if the patient is Black with NYHA class III-IV symptoms 1
• Torsemide 20mg is a loop diuretic appropriate for volume management but less effective than thiazide diuretics for blood pressure control 1

Stepwise Treatment Algorithm

Step 1: Switch Diuretic Class (Immediate Action)

Replace torsemide 20mg with chlorthalidone 12.5-25mg once daily in the morning. 1

• Loop diuretics like torsemide are necessary for volume control in severe HF but are significantly less effective than thiazide-like diuretics for blood pressure reduction 1
• Chlorthalidone provides 24-hour blood pressure control and has superior cardiovascular outcomes data compared to hydrochlorothiazide 1
• If the patient requires ongoing loop diuretic therapy for volume overload (NYHA class III-IV or severe renal impairment with eGFR <30 mL/min), add chlorthalidone to torsemide rather than replacing it 1

Monitor serum potassium and creatinine 2-4 weeks after initiating chlorthalidone to detect hypokalemia or changes in renal function, especially given concurrent Entresto use 1

Step 2: Consider Beta-Blocker Switch

Switch from labetalol 100mg TID to carvedilol 25mg BID (if not already maximized). 1

• Carvedilol is one of three beta-blockers proven to reduce mortality in HFrEF (along with metoprolol succinate and bisoprolol) 1
• Carvedilol provides superior blood pressure reduction compared to other beta-blockers due to combined α1-β1-β2 blocking properties 1
• Labetalol has limited evidence in HFrEF and is not the beta-blocker of choice according to heart failure guidelines 1

Step 3: Optimize Hydralazine-Nitrate Combination

Ensure the patient is on isosorbide dinitrate in combination with hydralazine (typically 20-40mg TID of isosorbide dinitrate with hydralazine 37.5-75mg TID). 1

• The combination of hydralazine plus isosorbide dinitrate reduces mortality and hospitalizations in Black patients with NYHA class III-IV HF 1
• Hydralazine alone without a nitrate lacks randomized trial evidence for benefit in HF 1

Step 4: If Blood Pressure Remains ≥140/90 mmHg After Steps 1-3

Add amlodipine 5-10mg once daily as the fourth antihypertensive agent. 1

• Amlodipine is the only calcium channel blocker proven safe in severe HFrEF (PRAISE trial) 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects and increased risk of worsening heart failure 1

Blood Pressure Targets

Target systolic blood pressure <130/80 mmHg, with a minimum acceptable target of <140/90 mmHg. 1

• Most successful heart failure trials achieved systolic blood pressure in the range of 110-130 mmHg 1
• For elderly patients (age not specified in your case), individualize based on tolerability, but do not withhold appropriate treatment intensification solely based on age 1
• In patients with very low diastolic blood pressure (<60 mmHg) who are elderly or have diabetes, lower systolic blood pressure slowly and monitor for myocardial ischemia or worsening heart failure 1

Critical Medications to Avoid

Do not add the following agents, as they worsen outcomes in HFrEF: 1

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)—negative inotropic effects
• Alpha-blockers (doxazosin, prazosin)—2-fold increased risk of heart failure hospitalization
• Centrally acting agents (clonidine, moxonidine)—moxonidine increased mortality in HF
• Direct vasodilators (minoxidil)—renin-related salt and fluid retention
• NSAIDs—interfere with blood pressure control, worsen volume status, and impair renal function

Monitoring Timeline

• 2-4 weeks after chlorthalidone initiation: Check blood pressure, serum potassium, and creatinine 1
• 2-4 weeks after carvedilol switch: Assess blood pressure, heart rate, and heart failure symptoms 1
• Goal: Achieve target blood pressure within 3 months of treatment modification 1
• Once stable: Monitor blood pressure and renal function every 4-6 months 1

Essential Pre-Treatment Steps

Before adding or switching medications, verify the following: 1

• Medication adherence—non-adherence is the most common cause of apparent treatment resistance
• Interfering medications—NSAIDs, decongestants, oral contraceptives, systemic corticosteroids
• Sodium intake—restrict to <2g/day for additive blood pressure reduction of 5-10 mmHg 1
• Alcohol intake—limit to <100g/week 1
• Secondary hypertension—if blood pressure remains severely elevated, screen for primary aldosteronism, renal artery stenosis, or obstructive sleep apnea 1

Common Pitfalls to Avoid

• Do not add spironolactone or eplerenone to Entresto (which contains valsartan) without extreme caution—dual RAS blockade plus aldosterone antagonism significantly increases hyperkalemia risk 1
• Do not delay treatment intensification—stage 2 hypertension (≥160/100 mmHg) requires prompt action to reduce cardiovascular risk 1
• Do not assume loop diuretics provide adequate blood pressure control—they are inferior to thiazide-like diuretics for hypertension management 1
• Do not uptitrate Entresto beyond maximum dose (97-103mg BID) as a primary blood pressure strategy—add complementary antihypertensive agents instead 2