Treatment of Hypertensive Systolic Heart Failure
For an adult with long-standing hypertension who now presents with systolic heart failure, initiate quadruple therapy with ACE inhibitors (or ARBs/ARNI), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, along with diuretics for symptom relief, targeting blood pressure <130/80 mmHg. 1, 2
Foundation Pharmacotherapy
Initiate all four medication classes rapidly—ideally within the first 3 months of diagnosis—and titrate to target doses over 2-4 weeks, not sequentially over months. 2
First-Line Agents (Start Simultaneously)
ACE Inhibitors are mandatory to reduce cardiovascular death and heart failure hospitalization 3, 1. If the patient develops cough or angioedema, substitute with an ARB 3. Consider upgrading to sacubitril/valsartan (ARNI) in patients who remain symptomatic despite optimal therapy, as it provides superior blood pressure control compared to ACE inhibitors or ARBs 4, 5.
Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) must be initiated in all stable patients to reduce mortality and hospitalization 3, 1. Continue beta-blockers during hospitalization unless the patient is hemodynamically unstable 2.
Mineralocorticoid receptor antagonists (spironolactone or eplerenone) should be added for patients with NYHA class II-IV symptoms and LVEF ≤35%, provided renal function is preserved and potassium is normal 3, 1. Monitor potassium and renal function closely to avoid hyperkalemia 2.
SGLT2 inhibitors are now recommended across the entire ejection fraction spectrum for proven mortality benefit, regardless of diabetes status 2, 6.
Diuretic Therapy
- Loop diuretics provide immediate symptom relief and should be initiated at doses equal to or exceeding chronic oral daily dose for any patient with signs of congestion 3, 1, 2. Thiazide diuretics are more effective than loop diuretics for blood pressure control but less effective for volume management in severe heart failure 3.
Blood Pressure Targets
Target blood pressure should be <130/80 mmHg, with consideration for lowering to <120/80 mmHg in appropriate patients. 3 In most successful heart failure trials, systolic blood pressure was lowered to 110-130 mmHg 3. The COPERNICUS trial demonstrated benefits with mean pretreatment blood pressure of 123/76 mmHg, suggesting lower targets may be beneficial 3.
Titration Strategy
Uptitrate guideline-directed medical therapy to maximally tolerated target doses rather than adding additional antihypertensives 2. If hypertension persists after optimizing these four medication classes, dihydropyridine calcium antagonists (amlodipine or felodipine) can be added, particularly if there is concomitant angina 3.
Drugs to Avoid
Never use the following agents in hypertensive systolic heart failure:
Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic properties and increased risk of worsening heart failure 3, 2
Alpha-blockers (doxazosin) due to 2.04-fold increased risk of developing heart failure compared to thiazide diuretics 3
Clonidine and moxonidine, as moxonidine was associated with increased mortality in heart failure patients 3
Monitoring Requirements
Check blood pressure, renal function, and electrolytes 1-2 weeks after medication initiation or dose changes, and every 6 months thereafter 1. Measure natriuretic peptides (BNP or NT-proBNP) at baseline to guide therapy 2.
Special Considerations
In elderly patients with wide pulse pressures, lowering systolic blood pressure may cause very low diastolic values (<60 mmHg), requiring careful assessment for myocardial ischemia and worsening heart failure 3. Lower blood pressure gradually in patients with coronary artery disease and avoid tachycardia 3.
Behavioral Modifications
Implement sodium restriction to <2-3 grams/day, daily weight monitoring at the same time each day, and a closely monitored exercise program in stable patients 3, 2. Avoid excessive alcohol consumption and smoking 2.
Device Therapy Consideration
Evaluate for implantable cardioverter-defibrillator (ICD) if LVEF ≤30-35%, NYHA class II-III on optimal medical therapy ≥3 months, and life expectancy >1 year 2. Consider cardiac resynchronization therapy (CRT) if LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, and NYHA class II-IV 2.