Management of Hypertension in Chronic Heart Failure

Saraswathy Manickavasagam; Ramanna Merla; Michael M Koerner; Ken Fujise; Sanjay Kunapuli; Salvatore Rosanio; Alejandro Barbagelata

Disclosures

Expert Rev Cardiovasc Ther. 2009;7(4):423-433. 

In This Article

Abstract and Introduction

Abstract

Chronic heart failure (CHF) is associated with frequent hospitalizations and high mortality. It affects more than 5 million individuals in the USA, and another 660,000 new cases are diagnosed each year; overall, heart failure (HF) now accounts for 7% of all deaths from cardiovascular disease. Hypertension (HTN) increases the risk of development of HF and it precedes it in 75% of cases. HF patients are nearly evenly divided between those with reduced left ventricular (LV) function or systolic dysfunction and those with preserved LV systolic function or diastolic dysfunction. The management of HTN in patients with CHF is challenging. Drugs such as β-blockers, angiotensin-converting enzyme inhibitiors, angiotensin receptor blockers, aldosterone receptor blockers, hydralazine and nitrates, which have shown mortality benefit in CHF and exert antihypertensive effects, should be used as first-line agents to control HTN in CHF. In addition, antihypertensive drugs such as α-receptor blockers that can increase mortality in HF should be avoided. The dihydropyridine group of calcium channel blockers are good antihypertensive medications with a neutral effect on mortality in patients with CHF. These may be used in CHF patients with refractory HTN. In patients with HF with reduced ejection fraction, HTN is treated differently in comparison to patients with HF with normal ejection fraction. This article reviews the treatment of essential HTN in patients at risk for developing HF, in the presence of HF and the latest developments in treatment that might benefit both HTN and HF management.

Introduction

Approximately 5 million people in the USA have chronic heart failure (CHF), and another 660,000 new cases are diagnosed each year.[1] Overall, heart failure (HF) is responsible for 12-15 million general practitioner visits and 6.5 million hospital-days annually.[1] According to a new analysis of 27 years of trend data from the National Hospital-discharge Surveys, HF has reached epidemic levels in the USA.[2] The population of HF patients is heterogeneous, ranging from the asymptomatic to those with chronic decompensation and advanced symptoms. HF patients are nearly evenly divided between those with reduced left ventricular (LV) systolic function (HF with reduced ejection fraction [HFREF]) and those with preserved LV systolic function (HF with normal ejection fraction [HFNEF]). The latter group is associated with essential hypertension (HTN) more often.[3,4]

Hypertension is becoming increasingly prevalent, and it is estimated that 50 million or more Americans require treatment for it.[5] Approximately more than two-thirds of patients with HF have a past or current history of HTN.[6,7] HTN increases the risk of HF two- to threefold and is an important cause of HF in African-Americans and the elderly.[5] In these patients, HTN may have caused the HF or be an incidental comorbidity if the HF has resulted from other diseases, such as coronary atherosclerosis. Nonetheless, HTN increases afterload, making it especially deleterious in HF patients.

Many drugs that have shown mortality benefit in CHF also have antihypertensive effects and should be used as first-line agents to control HTN in HF. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) have strong evidence to support their use in HTN patients at risk for HF, as well as in patients with HFREF.[8,9,10,11,12,13,14,15,16] Additionally, ARBs have greater but conflicting evidence for use in patients with preserved ejection fraction.[17,18] Thiazides are the first-line drugs in patients with HTN at risk for HF.[5] However, in patients with established HF, loop diuretics are prescribed more often and a thiazide may be added to promote diuresis by sequentially blocking sodium transport in renal tubules in cases where volume overload persists, despite loop diuretics.[19] Conflicting data exist in the use of β-blockers for patients with HTN without HF and in patients with HFNEF.[20,21,22,23,24,25] Extensive data support the use of β-blockers in patients with HFREF, especially carvedilol and metoprolol.[26,27,28] Calcium channel blockers are widely used to treat HTN in patients at risk for HF[5]; however, they are not considered in the management of HTN in HFREF.[19,29,30] A dihydropyridine group of calcium channel blockers could be used to control HTN only once other medications have failed, since they exert a neutral effect on mortality in HFREF patients.[19,29,30] Potentially, they could be beneficial in patients with HFNEF. Aldosterone receptor blockers significantly decreased blood pressure in patients with HTN at risk for HF requiring three or more antihypertensive medications.[31] In patients with HFREF, aldosterone receptor blockers decrease both HTN and mortality.[32,33] This article reviews the current treatment of essential HTN with and without HF and the latest developments in the treatment of HTN in HF.

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