Treatment of Hypertension in Association with Heart Failure

  1. In patients with systolic dysfunction (EF <40%), ACE inhibitors (Grade A) and β-blockers (Grade A) are recommended for initial therapy. Aldosterone antagonists (mineralcorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated BNP or NT-proBNP level, or NYHA Class II to IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when adding an aldosterone antagonist to ACE inhibitor or ARB. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide/thiazide-like diuretics for BP control, Grade D for loop diuretics for volume control). Beyond considerations of blood pressure control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects become manifest (Grade B).
  2. An ARB is recommended if ACE inhibitors are not tolerated (Grade A).
  3. A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B).
  4. For hypertensive patients whose blood pressure is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB due to potential adverse effects such as hypotension, hyperkalemia and worsening renal function (Grade C). Additional therapies may also include dihydropyridine CCBs (Grade C).
  5. An Angiotensin Receptor-Neprilysin Inhibitor combination should be used in place of an ACE inhibitor or ARB for patients with HFrEF (EF <40%) who remain symptomatic despite treatment with appropriate dose of guideline-directed HF therapy (usually a β- blocker, an ACE-Inhibitor or ARB, and where appropriate, a mineralcorticoid antagonist) (Grade A; new guideline). Eligible patients must have a serum potassium <5.2 mmol/L, an eGFR greater or equal to 30 mL/min/1.73m2 and close surveillance of serum potassium and creatinine (Grade A; new guideline).