What is the recommended management for a patient with heart failure secondary to chronic hypertension?

Management of Hypertensive Heart Failure

In patients with heart failure secondary to chronic hypertension, initiate ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) combined with beta-blockers as foundational therapy, add diuretics for volume control, and include mineralocorticoid receptor antagonists for symptomatic patients with reduced ejection fraction. 1, 2

Pharmacological Management Algorithm

First-Line Therapy for HFrEF (Ejection Fraction ≤40%)

Start with ACE inhibitors as the cornerstone medication—they reduce mortality, prevent hospitalization, and control blood pressure in hypertensive heart failure patients. 1 If ACE inhibitors are not tolerated due to cough or angioedema, substitute with an ARB. 1, 2

Add a beta-blocker (specifically carvedilol, metoprolol succinate, or bisoprolol) in combination with the ACE inhibitor—this dual therapy is mandatory and reduces both mortality and heart failure hospitalizations. 1, 2 Beta-blockers should be initiated even if blood pressure is already controlled, as their benefit extends beyond blood pressure reduction. 2, 3

Include diuretics for all patients with signs or symptoms of fluid overload (pulmonary congestion, peripheral edema, dyspnea). 1 Use loop diuretics (furosemide, bumetanide) for moderate to severe heart failure, or thiazides for mild volume overload. 1, 2 Diuretics provide rapid symptomatic relief and improve exercise tolerance, though they must always be combined with ACE inhibitors. 1

Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone) for patients who remain symptomatic (NYHA class II-IV) despite ACE inhibitor and beta-blocker therapy, particularly when ejection fraction is <40%. 1, 2, 3 This further reduces mortality and hospitalization risk. 1

Advanced Therapy Considerations

Consider sacubitril/valsartan (ARNI) as a replacement for ACE inhibitors in ambulatory patients with HFrEF who remain symptomatic despite optimal medical therapy—this provides superior blood pressure control and further reduces heart failure hospitalization and death compared to ACE inhibitors alone. 1

Add SGLT2 inhibitors to the regimen for patients with HFrEF or HFmrEF (ejection fraction 40-49%), as they improve outcomes independent of diabetes status. 1, 2, 3

For self-identified African American patients with NYHA class III-IV symptoms, add hydralazine plus isosorbide dinitrate to the standard regimen (diuretic, ACE inhibitor/ARB, beta-blocker) to reduce morbidity and mortality. 1, 2, 3

Blood Pressure Targets

Target systolic blood pressure of 120-130 mmHg for most patients with heart failure, though individualized targets are appropriate based on age and comorbidities. 1, 2, 3 For patients ≥65 years old, a systolic blood pressure range of 130-139 mmHg is acceptable. 1, 2, 3

Avoid lowering diastolic blood pressure below 60 mmHg, particularly in elderly patients or those with diabetes, as excessive diastolic lowering may compromise coronary perfusion. 2, 3 The key principle: do not withhold or reduce doses of guideline-directed medical therapy solely because of low blood pressure if the patient tolerates the medications without symptomatic hypotension. 3, 4

Management of HFpEF (Preserved Ejection Fraction)

For patients with heart failure and preserved ejection fraction, the evidence base is weaker, but ACE inhibitors or ARBs remain reasonable first-line agents for blood pressure control and may reduce hospitalizations. 1, 5 Beta-blockers are also reasonable for blood pressure control in this population. 1 SGLT2 inhibitors show promise for HFpEF and should be considered. 2, 3

Medications to Avoid

Never use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with HFrEF—they worsen heart failure and increase hospitalization risk due to negative inotropic effects. 1, 2, 3

Avoid centrally-acting agents like clonidine and moxonidine, as moxonidine increased mortality in heart failure trials. 1, 2, 3

Use alpha-blockers (doxazosin) only as a last resort when all other options have failed, as they doubled heart failure risk in the ALLHAT trial. 1, 2

Avoid NSAIDs as they worsen blood pressure control, promote fluid retention, and impair renal function. 1, 2

Do not use hydralazine without a nitrate in heart failure patients. 2

Initiation and Monitoring Protocol

When starting ACE inhibitors: 1

• Review and potentially reduce diuretic doses 24 hours before initiation to avoid excessive hypotension
• Start with low doses and uptitrate to target doses proven effective in clinical trials
• Check blood pressure, renal function (creatinine), and electrolytes (potassium) 1-2 weeks after each dose increase, at 3 months, then every 6 months
• Avoid potassium-sparing diuretics during initial ACE inhibitor titration
• If creatinine increases >30% or potassium rises >5.5 mEq/L, reduce dose or temporarily hold medication

A critical pitfall: Many clinicians underdose ACE inhibitors or beta-blockers due to concerns about blood pressure or heart rate. 2, 3 The evidence shows these medications improve outcomes across a wide range of baseline blood pressures, and patients with lower baseline blood pressure may actually derive greater absolute risk reduction. 4

Resistant Hypertension Management

For patients with persistent hypertension despite optimal heart failure therapy, add low-dose spironolactone if not already prescribed. 1, 2 If spironolactone is not tolerated, consider eplerenone, amiloride, or higher-dose thiazide diuretics. 1, 2

Carvedilol may be more effective than other beta-blockers for resistant hypertension due to its combined alpha-1, beta-1, and beta-2 blocking properties. 2

Dihydropyridine calcium channel blockers (amlodipine, felodipine) are safe additions for refractory hypertension in heart failure patients when other agents are insufficient, as they do not worsen heart failure outcomes. 1, 5

Non-Pharmacological Management

Sodium restriction to approximately 2g per day is reasonable for symptomatic patients to reduce congestion, though extreme restriction is not necessary. 1, 2

Regular physical activity and exercise training (≥150 minutes per week of moderate-intensity aerobic exercise plus resistance training 2-3 times weekly) are safe and effective for improving functional status in stable heart failure patients. 1, 2

Weight optimization, smoking cessation, and alcohol moderation are essential lifestyle modifications. 1

Prevention of Heart Failure in Hypertensive Patients

Aggressive blood pressure control prevents heart failure development—treatment of hypertension is the single most effective intervention to prevent or delay heart failure onset. 1, 6, 7 Target blood pressure should be reduced to at least <140/90 mmHg, and to <130/80 mmHg in high-risk patients including those with diabetes or evidence of target organ damage. 1