XIII. Treatment of hypertension in association with heart failure




  1. In patients with systolic dysfunction (ejection fraction < 40%), ACE inhibitors (Grade A) and b-blockers (Grade A) are recommended for initial therapy. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be combined for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide level, or New York Heart Association class II-IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when an aldosterone antagonist is used with an 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 BP 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 toler-ated (Grade A).
  3. A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contra-indicated or not tolerated (Grade B).
  4. For hypertensive patients whose BP is not controlled, an ARB may be used with an ACE inhibitor and other anti-hypertensive drug treatment (Grade A). Careful moni-toring should be used if an ACE inhibitor and an ARB are used together because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies may also include dihy-dropyridine CCBs (Grade C).
  5. An angiotensin receptor-neprilysin inhibitor combination should be used in place of an ACE inhibitor or ARB for patients with heart failure with reduced ejection fraction (HFrEF) (ejection fraction < 40%) who remain symp-tomatic despite treatment with an appropriate dose of guideline-directed heart failure therapy (usually a b-blocker, an ACE inhibitor or ARB, and where appropriate, a mineralocorticoid receptor antagonist; Grade A). Eligible patients must have a serum potassium level < 5.2 mmol/L, an estimated GFR (eGFR) 30 mL/min/1.73 m2, and close surveillance of serum potassium and creatinine (Grade A).