Management of Hypertension in Chronic Heart Failure

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


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

In This Article

Management of HTN in Patients at Risk of HF

Long-term treatment of both systolic and diastolic HTN reduces the risk of developing HF by 50%.[34] The goal of the Heart Failure Society of America for patients with renal insufficiency (> 1 g/day of proteinuria) and those with a high risk of developing HF is 125/75 mmHg, and 130/85 mmHg in patients with less than 1 g/day of proteinuria.[35]

The The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommendations, based on the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) data, recommend that a thiazide diuretic, such as hydrochlorthiazide or chlorthalidone, should be first-line therapy for HTN in patients without diabetes, angina, ischemic heart disease, HF or chronic kidney disease,[5] which is fortuitous given the low cost of these drugs.[36] Hydrochlorothiazide can normalize blood pressure in up to 46% of patients with mild HTN.[37] Thiazides can reduce the incidence of HF in patients with HTN and prevent HTN-related mortality and morbidity, but fail to prolong survival if patients already have HF.[19]

In hypertensive patients with diabetes, ACE inhibitors are preferred as they slow the progression of diabetic renal disease, prevent recurrent events, such as myocardial infarction in vascular patients, and may prevent the development of HF.[38,39,40]

β-adrenergic receptor blockers are discouraged for the treatment of HTN as they have been associated with increased stroke, especially in the elderly, and do not reduce all-cause mortality or cardiovascular morbidity and mortality.[20,21,22,23] Although these findings were observed in studies predominantly using atenolol, the European Society of Hypertension, European Society of Cardiology[41] and NICE discourage β-blocker use for HTN unless there are compelling reasons to do otherwise.[42] Nevertheless, β-adrenergic blockade is preferred in hypertensive patients with previous myocardial infarction, in whom they reduce cardiovascular mortality and provide benefits beyond those attributable to blood pressure lowering alone.[43]

Most patients require more than one agent for optimal blood pressure control. Guidelines recommend starting two drugs for blood pressures 20 mmHg or more above the desired goal.[5,44] Patients not responding completely to one drug have almost a 50% likelihood of achieving their blood pressure goal on a second one.[45] Not all two drug regimes have similar benefits. While thiazide diuretics and calcium channel blockers work well in African-American and older patients (aged 55 years and above),[46,47] younger patients respond more favorably to ACE inhibitors and ARBs.[8,9] In the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, a significant decrease in cardiovascular mortality was found in the benazepril plus amlodipine arm compared with the benazepril plus hydrochlorothiazide arm.[48] The mean difference in blood pressure between the two groups was only 0.9 mmHg systolic and 1.1 mmHg diastolic, which was statistically significant.[48] The cardiovascular end points did not include development of HF. Nevertheless, it is important to note that there was a significant decrease in myocardial infarction, which is a major risk factor for the development of HF. In patients requiring three or more different hypertensive medications, adding spironolactone can decrease the mean systolic blood pressure by more than 25 mmHg and diastolic blood pressure by more than 10 mmHg.[31] Combination of ACE inhibitors and ARBs is associated with increased adverse events and should be avoided.[49]

Treatment of HTN with α-adrenergic blockade is generally restricted to patients with urinary tract obstruction or benign prostatic hyperplasia, since these drugs may increase the incidence of HF. In the ALLHAT study, secondary end points (major cardiovascular disease events, mostly driven by the occurrence of HF) were 25% higher in the doxazosin than the chlorthalidone arm, and hospitalization for HF was twice as likely (Figure 1).[36]

Figure 1.

Algorithm for treatment of hypertension without heart failure (adapted from JNC-7 guidelines). ACE-I = Angiotensin-converting enzyme; ARB = Angiotensin receptor blocker; CCB = alcium channel blocker; DBP = Diastolic blood pressure; MI = Myocardial infaction; SBP = Systolic blood pressure.