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Treatment of Hypertension in Patients With CAD
Treatment of Hypertension in Patients With Coronary Artery Disease.
A Scientific Statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension
Recommendations
- 1.The treatment of hypertension in patients with HF should include management of risk factors such as dyslipidemia, obesity, diabetes mellitus, smoking, and dietary sodium and a closely monitored exercise program (Class I; Level of Evidence: C).
- 2.Drugs that have been shown to improve outcomes for patients with HF with reduced ejection fraction generally also lower BP. Patients should be treated with ACE inhibitors (or ARBs), β-blockers (carvedilol, metoprolol succinate, bisoprolol, or nebivolol), and aldosterone receptor antagonists (Class I; Level of Evidence: A).
- 3.Thiazide or thiazide-type diuretics should be used for BP control and to reverse volume overload and associated symptoms. In patients with severe HF (NYHA class III and IV) or those with severe renal impairment (estimated glomerular filtration rate <30 mL/min), loop diuretics should be used for volume control, but they are less effective than thiazide or thiazide-type diuretics in lowering BP. Diuretics should be used together with an ACE inhibitor or ARB and a β-blocker (Class I; Level of Evidence: C).
- 4.Studies have shown equivalence of benefit of ACE inhibitors and the ARBs candesartan or valsartan in HF with reduced ejection fraction. Either class of agents is effective in lowering BP(Class I; Level of Evidence: A).
- 5.The aldosterone receptor antagonists spironolactone and eplerenone have been shown to be beneficial in HF and should be included in the regimen if there is HF (NYHA class II–IV) with reduced ejection fraction (<40%). One or the other may be substituted for a thiazide diuretic in patients requiring a potassium-sparing agent. If an aldosterone receptor antagonist is administered with an ACE inhibitor or an ARB or in the presence of renal insufficiency, serum potassium should be monitored frequently. These drugs should not be used, however, if the serum creatinine level is ≥2.5 mg/dL in men or ≥2.0 mg/dL in women or if the serum potassium level is ≥5.0 mEq/L. Spironolactone or eplerenone may be used with a thiazide or thiazide-like diuretic, particularly in patients with resistant hypertension (Class I; Level of Evidence: A).
- 6.Hydralazine plus isosorbide dinitrate should be added to the regimen of diuretic, ACE inhibitor or ARB, and β-blocker in African American patients with NYHA class III or IV HF with reduced ejection fraction (Class I; Level of Evidence: A). Others may benefit similarly, but this has not yet been tested.
- 7.In patients who have hypertension and HF with preserved ejection fraction, the recommendations are to control systolic and diastolic hypertension (Class I; Level of Evidence: A), ventricular rate in the presence of atrial fibrillation (Class I; Level of Evidence: C), and pulmonary congestion and peripheral edema (Class I; Level of Evidence: C).
- 8.Use of β-adrenergic blocking agents, ACE inhibitors, ARBs, or CCBs in patients with HF with preserved ejection fraction and hypertension may be effective to minimize symptoms of HF (Class IIb; Level of Evidence: C).
- 9.In IHD, the principles of therapy for acute hypertension with pulmonary edema are similar to those for STEMI and NSTEMI, as described above (Class I; Level of Evidence: A). If the patient is hemodynamically unstable, the initiation of these therapies should be delayed until stabilization of HF has been achieved.
- 10.Drugs to avoid in patients with hypertension and HF with reduced ejection fraction are nondihydropyridine CCBs (such as verapamil and diltiazem), clonidine, moxonidine, and hydralazine without a nitrate (Class III Harm; Level of Evidence: B). α-Adrenergic blockers such as doxazosin should be used only if other drugs for the management of hypertension and HF are inadequate to achieve BP control at maximum tolerated doses. Nonsteroidal anti-inflammatory drugs should also be used with caution in this group, given their effects on BP, volume status, and renal function (Class IIa; Level of Evidence: B).
- 11.The target BP is <140/90 mm Hg, but consideration can be given to lowering the BP even further, to <130/80 mm Hg. In patients with an elevated DBP who have CAD and HF with evidence of myocardial ischemia, the BP should be lowered slowly. In older hypertensive individuals with wide pulse pressures, lowering SBP may cause very low DBP values (<60 mm Hg). This should alert the clinician to assess carefully any untoward signs or symptoms, especially those caused by myocardial ischemia and worsening HF (Class IIa; Level of Evidence: B). Octogenarians should be checked for orthostatic changes with standing, and an SBP <130 mm Hg and a DBP <65 mm Hg should be avoided.
http://content.onlinejacc.org/article.aspx?articleid=2212514
