For a patient with recent myocardial infarction and hypertension, which antihypertensive drug classes are recommended?

Antihypertensive Management Post-Myocardial Infarction

For patients with recent myocardial infarction and hypertension, you should initiate combination therapy with a beta-blocker (specifically carvedilol, metoprolol succinate, or bisoprolol) plus an ACE inhibitor (or ARB if ACE inhibitor intolerant) as first-line therapy, targeting a blood pressure <130/80 mmHg. 1

First-Line Therapy: Beta-Blockers

• Beta-blockers are mandatory as first-line therapy post-MI, reducing all-cause mortality by 23% in randomized trials. 1
• Use guideline-directed medical therapy (GDMT) beta-blockers: carvedilol, metoprolol succinate, bisoprolol, nadolol, propranolol, or timolol. 1
• Beta-blockers should be continued beyond 3 years post-MI for long-term hypertension management. 1
• Early administration of beta-blockers after MI reduces the incidence of recurrent myocardial infarction and death, with benefits attributable to both specific protective properties and blood pressure reduction. 2

First-Line Therapy: ACE Inhibitors or ARBs

• ACE inhibitors are equally essential as first-line therapy alongside beta-blockers for patients with CAD and hypertension. 2, 1
• ACE inhibitors reduce mortality rates in patients with MI, particularly those with LV systolic dysfunction, and reduce cardiovascular mortality by 20-22%. 2, 3
• Ramipril produced a 22% reduction in MI, stroke, or CVD death compared with placebo over 5 years. 1
• Perindopril reduced CVD death, MI, or cardiac arrest by 20% compared with placebo in patients with stable ischemic heart disease. 1
• ARBs (particularly valsartan) are Class I alternatives for patients intolerant to ACE inhibitors, with valsartan demonstrating equivalence to captopril in patients at high risk for cardiovascular events after MI. 2, 3
• Do not combine ACE inhibitors with ARBs, as this increases adverse events without additional benefit. 2, 4

Additional Agents for Uncontrolled Hypertension or Persistent Angina

• Add dihydropyridine calcium channel blockers (e.g., amlodipine) if angina persists despite beta-blocker therapy and hypertension remains uncontrolled. 1
• Dihydropyridine CCBs are effective antianginal drugs that lower BP when added to beta-blockers. 1
• Calcium antagonists are alternatives to beta-blockers for angina treatment but are not generally recommended for secondary cardiac protection due to relative inability to prevent ventricular dilatation and heart failure. 2
• Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in post-MI patients with heart failure or reduced LVEF. 3

Aldosterone Receptor Antagonists

• Add mineralocorticoid receptor antagonists (MRAs) such as eplerenone or spironolactone for post-MI patients with LVEF ≤40% and heart failure or diabetes. 3
• Eplerenone reduced total mortality by 15% and morbidity in patients with MI complicated by LV dysfunction and either heart failure or diabetes mellitus. 2, 3
• Spironolactone decreased morbidity and death in patients with severe heart failure, half of whom had an ischemic origin. 2

Thiazide Diuretics

• If BP goal is not met with beta-blocker plus ACE inhibitor/ARB, add a thiazide diuretic. 1
• Thiazide diuretics are suitable for initiation and maintenance of antihypertensive treatment and can adequately lower blood pressure. 2
• In patients with congestive heart failure, thiazide and loop diuretics can be used on top of beta-blockers, ACE inhibitors, ARBs, and antialdosterone drugs. 2

Blood Pressure Target

• Target blood pressure <130/80 mmHg in patients with CAD and hypertension. 2, 1, 3
• Reduction of SBP to <130/80 mmHg reduces CVD complications by 25% and all-cause mortality by 27%. 1
• Avoid systolic BP <100 mmHg, especially in the acute phase, as this increases risk of cardiogenic shock. 3
• Exercise caution when lowering DBP below 60 mmHg in patients with diabetes or those over age 60, as very low DBP values may occur when lowering SBP in older patients with wide pulse pressures. 2

Treatment Algorithm

1. Initiate GDMT beta-blocker + ACE inhibitor (or ARB if intolerant) immediately. 1, 3
2. If angina persists, add dihydropyridine CCB to beta-blocker. 1
3. If BP goal (<130/80 mmHg) is not met, add thiazide diuretic. 1
4. For patients with LVEF ≤40% and heart failure or diabetes, add MRA (eplerenone or spironolactone). 3

Critical Considerations for Inferior Wall MI

• Check for right ventricular (RV) involvement before initiating antihypertensives, as patients with inferior MI and RV involvement are preload-dependent and can experience profound hypotension with vasodilators. 3
• Look for ST-segment elevation ≥1mm in right precordial leads (V3R-V4R) to identify RV infarction. 3
• Maintain adequate preload and avoid excessive diuresis or aggressive vasodilation in RV infarction. 3
• Avoid nitrates in RV infarction, as they can cause profound hypotension. 3

Medications to Avoid

• Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in post-MI patients with heart failure or reduced LVEF. 3
• Avoid NSAIDs and COX-2 inhibitors due to sodium retention, worsened heart failure, and increased cardiovascular risk. 3
• Avoid thiazolidinediones due to fluid retention. 3
• Beta-blockers should not be used in patients with the metabolic syndrome or at high risk of incident diabetes when combined with thiazide diuretics, though vasodilator beta-blockers (carvedilol, nebivolol) have less dysmetabolic action. 2