Synopsis
Antecedent hypertension is present in 75% of patients with chronic HF. In the Cardiovascular Health Study and the Health, Aging and Body Composition Study , 11.2% of 4408 persons (53.1% women, with a mean age of 72.8 years, living in the community, and not receiving antihypertensive drugs at baseline) developed HF over 10 years. Compared with those with an average SBP <120 mm Hg, the adjusted incidence of HF was increased 1.6, 2.2, and 2.6 times in those with average SBPs between 120 and 139 mm Hg, between 140 and 159 mm Hg, and ≥160 mm Hg, respectively.
No RCTs are available that compare one BP-lowering agent to another for the management of patients with HF. The following recommendations for treatment of hypertension in HF are based on use of drugs that lower BP and also have compelling indications for management of HF (with HFrEF or HFpEF) as recommended in current ACC/AHA guidelines.
Recommendation-Specific Supportive Text
1. This recommendation is based on guidance in the 2017 ACC/AHA/HFSA guideline focused update on heart failure (see figure from the HF focused update that is reproduced in Online Data Supplement A). Lifestyle modification, such as weight loss and sodium reduction, may serve as adjunctive measures to help these agents work better. No RCT evidence is available to support the superiority of one BP-lowering medication with compelling indications for treatment of HFrEF over another. Medications with compelling indications for HF that may be used as first-line therapy to treat high BP include ACE inhibitors or ARBs, angiotensin receptor– neprilysin inhibitors, mineralocorticoid receptor antagonists, diuretics, and GDMT beta blockers (carvedilol, metoprolol succinate, or bisoprolol).
Clinical trials evaluating goal BP reduction and optimal BP-lowering agents in the setting of HFrEF and concomitant hypertension have not been performed. However, in patients at higher CVD risk, BP lowering is associated with fewer adverse cardiovascular events. GDMT for HFrEF with agents known to lower BP should consider a goal BP reduction consistent with a threshold now associated with improved clinical outcomes but not yet proven by RCTs in an HF population.
2. Nondihydropyridine CCBs (verapamil, diltiazem) have myocardial depressant activity. Several clinical trials have demonstrated either no clinical benefit or even worse outcomes in patients with HF treated with these drugs. Therefore, nondihydropyridine CCBs are not recommended in patients with hypertension and HFrEF.
Synopsis
Approximately 50% of patients with HF have HFpEF. The ejection fraction in these studies has varied from >40% to ≥55%. Patients with HFpEF are usually older women with a history of hypertension. Obesity, CHD, DM, AF, and hyperlipidemia are also highly prevalent in patients with HFpEF. Hypertension is the most important cause of HFpEF, with a prevalence of 60% to 89% in large RCTs, epidemiological studies, and HF registries. Patients with HFpEF also have an exaggerated hypertensive response to exercise. Hypertensive acute pulmonary edema is an expression of HFpEF. BP control is important for prevention of HFpEF in patients with hypertension. ALLHAT showed that treatment of hypertension with chlorthalidone reduced the risk of HF compared with amlodipine, doxazosin, and lisinopril. Improved BP control also reduces hospitalization, CVD events, and mortality.
Recommendation-Specific Supportive Text
1. Diuretics are the only drugs used for the treatment of hypertension and HF that can adequately control the fluid retention of HF. Appropriate use of diuretics is also crucial to the success of other drugs used for the treatment of hypertension in the presence of HF. The use of inappropriately low doses of diuretics can result in fluid retention. Conversely, the use of inappropriately high doses of diuretics can lead to volume contraction, which can increase the risk of hypotension and renal insufficiency. Diuretics should be prescribed to all patients with hypertension and HFpEF who have evidence of, and to most patients with a prior history of, fluid retention.
2. In a trial of patients with HFpEF and MI, patients randomized to propranolol had at 32-month follow-up a 35% reduction in mortality rate. After 21 months of treatment in patients with HFrEF and HFpEF, compared with placebo, those randomized to nebivolol had a 14% reduction in mortality or CVD hospitalization if they had HFrEF and a 19% reduction if they had HFpEF. In patients with HFpEF, the primary outcome (a composite of CVD death or HF hospitalization) was observed in 22% for candesartan and 24% for placebo (11% reduction), but fewer patients receiving candesartan were hospitalized for HF. The use of nitrates in the setting of HFpEF is associated with a signal of harm and in most situations should be avoided. For many other common antihypertensive agents, including alpha blockers, beta blockers, and calcium channel blockers, limited data exist to guide the choice of antihypertensive therapy in the setting of HFpEF. Reninangiotensin- aldosterone system inhibition, however, with ACE inhibitor or ARB and especially MRA would represent the preferred choice. A shared decision-making discussion, with the patient influenced by clinician judgment, should drive the ultimate choice of antihypertensive agents.
REF. 2017 High Blood Pressure Clinical Practice Guideline
