What antihypertensive regimen is appropriate for a patient with coronary artery disease and chronic congestive heart failure who also has hypertension?

Antihypertensive Management in CAD with Heart Failure

In patients with coronary artery disease and congestive heart failure, initiate triple therapy with an ACE inhibitor (or ARB if ACE-intolerant), a beta-blocker, and a diuretic (thiazide for mild HF, loop diuretic for moderate-severe HF), targeting blood pressure <130/80 mmHg. 1

First-Line Therapeutic Foundation

The cornerstone regimen must include:

• ACE inhibitors or ARBs: These reduce mortality and recurrent MI in post-MI patients and those with systolic dysfunction, providing both blood pressure control and direct cardioprotection 1
• Beta-blockers: Essential for mortality reduction post-MI and in heart failure with reduced ejection fraction, with benefits extending beyond blood pressure lowering 1
• Diuretics: Thiazide or thiazide-type diuretics for mild HF; loop diuretics (furosemide, torsemide) for moderate-severe HF with volume overload 1

Blood Pressure Targets

Target <130/80 mmHg in patients with both CAD and heart failure 1. This lower target is supported by the ACC/AHA 2017 guidelines for patients with clinical CVD 1. The European guidelines similarly recommend achieving BP around 130/80 mmHg or less, with demonstrated benefit even when initial BP is <140/90 mmHg 1.

Critical caveat: Lower blood pressure gradually in CAD patients to avoid precipitating myocardial ischemia, and avoid diastolic BP <60-65 mmHg which may worsen coronary perfusion 1, 2.

Medication Selection Algorithm

Step 1: Optimize Beta-Blocker Therapy

• Start or uptitrate beta-blocker (e.g., carvedilol up to 50 mg twice daily, metoprolol succinate, or bisoprolol) 2
• Beta-blockers provide dual mortality benefit in both CAD and HFrEF 1

Step 2: Add or Optimize ACE Inhibitor/ARB

• ACE inhibitors are preferred (ramipril, perindopril, lisinopril) 1
• Use ARB only if ACE inhibitor causes intolerable cough 1
• Never combine ACE inhibitor with ARB - increases hyperkalemia and acute kidney injury risk without benefit 3

Step 3: Diuretic Selection Based on HF Severity

• Mild HF: Thiazide or thiazide-type diuretics (chlorthalidone 12.5-25 mg daily preferred over HCTZ) 1, 3
• Moderate-severe HF: Loop diuretics (furosemide, torsemide) for greater diuresis and efficacy in renal impairment 1

Step 4: Add Mineralocorticoid Receptor Antagonist

• Spironolactone or eplerenone on top of diuretics for additional mortality benefit in HFrEF 1

Step 5: Additional BP Control if Needed

• Add dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily or felodipine) if BP remains uncontrolled 1, 4
• Amlodipine is safe in HFrEF with EF ≥40% and provides 24-hour BP control 4
• Avoid non-dihydropyridine CCBs (diltiazem, verapamil) in HFrEF due to negative inotropic effects 1, 2, 4

Critical Contraindications and Warnings

Calcium channel blockers to avoid:

• Non-dihydropyridine CCBs (diltiazem, verapamil) should be avoided in HFrEF unless absolutely necessary for BP or angina control, as they worsen heart failure outcomes 1, 2

Monitoring requirements:

• Check electrolytes (sodium, potassium) and renal function 2-4 weeks after initiating or uptitrating diuretics or RAAS inhibitors 3
• Monitor for hyperkalemia when combining ACE inhibitor/ARB with aldosterone antagonists 3
• Assess volume status and dry weight regularly, especially in HF patients 2

Evidence Strength and Nuances

The recommendation for beta-blockers, ACE inhibitors, and diuretics in this population is supported by the highest quality evidence (Class I recommendations) from both European and American guidelines 1. The 2007 ESH/ESC guidelines explicitly state that in congestive heart failure, "treatment can make use of thiazide and loop diuretics, as well as β-blockers, ACE inhibitors, angiotensin receptor antagonists and antialdosterone drugs on top of diuretics" 1.

The 2017 ACC/AHA guidelines emphasize that in stable ischemic heart disease with hypertension, guideline-directed medical therapy (beta-blockers, ACE inhibitors/ARBs) should be first-line, with addition of dihydropyridine CCBs and thiazide diuretics as needed 1.

Important distinction: While calcium antagonists should generally be avoided in HF, they are acceptable "unless needed to control BP or anginal symptoms" 1. When needed, only dihydropyridine CCBs (amlodipine, felodipine) should be used 1, 4.