6.10 Hypertension in Coronary Artery Diseases and Heart Failure

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There are strong relationships between CAD and hypertension¹¹. Different RCTs show that there is compelling beneficial effect of BP treatment on reducing the risk of myocardial infarction. A recent meta-analysis of RCTs of antihypertensive therapy showed that for every 10-mmHg reduction in SBP, CAD was reduced by 17%^38,39. The benefits of reducing cardiac events are also evident in high-risk groups, such as those with diabetes^{36, 38-40}.

A target BP approximately <130/80 mmHg in patients with CAD appears safe and can be recommended¹¹. In hypertensive patients with CAD, beta-blockers and RAS blockers may improve outcomes in post-myocardial infarction period and reduces the mortality in ACS^9,11. In patients with symptomatic angina, beta-blockers and rate limiting calcium antagonists are the preferred components of the drug treatment strategy. In STEMI in addition to antiplatelet and statin, beta-blockers and RAS blockers are the treatment of choice. If BP is not controlled with beta-blockers and RAS blockers, Alpha-1 blockers can be used¹¹. Calcium antagonists both dihydropyridine and non-dihydropyridine are contraindicated with CAD with reduced ejection fraction (LVEF <40%)¹¹. Nondihydropyridine CCBs should be avoided with concomitant use of Beta Blockers as there is increased risk of Bradycardia and AV block¹¹.

Hypertension is the leading risk factor for the development of heart failure and most patients with heart failure will have an antecedent history of hypertension. This may be a consequence of CAD, which results in heart failure with reduced ejection fraction (HFrEF)^11,41. Hypertension also causes left ventricular hypertrophy (LVH), which impairs LV relaxation (so-called diastolic dysfunction) and is a potent predictor of heart failure, even when LV systolic function is normal and there is no preceding myocardial infarction⁴².

Treating hypertension has a major impact on reducing the risk of incident heart failure and heart failure hospitalization, especially in old and very old patients²⁷. The most effective antihypertensive in the above-mentioned conditions are diuretics, betablockers, ACE inhibitors, or ARBs^1,6. This has been observed that CCBs are being less effective in comparative trials⁹.

Reducing BP can also lead to the regression of LVH, which has been shown to be accompanied by a reduction of CV events and mortality^11,43. The magnitude of LVH regression is associated with baseline LV mass, duration of therapy, and the SBP reduction. The drugs used with ARBs, ACE inhibitors and CBBs causing more effective LVH regression than beta-blockers or diuretics^11,43.

In patients with HFrEF, antihypertensive drug treatment should start (if not already initiated) when BP is >140/90 mmHg. It is unclear how low BP should be lowered in patients with heart failure. Outcomes for patients with heart failure have repeatedly been shown to be poor if BP values are low, which suggests (although data interpretation is made difficult by the possibility of reversed causality) that it may be wise to avoid actively lowering BP to <120/70 mmHg^11,44.

Heart failure guideline-directed medications are recommended for the treatment of hypertension in patients with HFrEF. ACE inhibitors, ARBs, Angiotensin receptor-neprilysin inhibitor (ARNI) (i.e. sacubitril and valsartan), beta-blockers, and MRAs (e.g. spironolactone and epleronone) are all effective in improving clinical outcome in patients with established HFrEF, whereas for diuretics, evidence is limited to symptomatic improvement. Sacubitril / valsartan lowers BP and has also been shown to improve outcomes in patients with HFrEF and is indicated for the treatment of HFrEF as a better alternative to ACE inhibitors or ARBs.⁵⁴ Non-dihydropiridine CCBs (diltiazem and verapamil), alpha-blockers, and centrally acting agents, such as moxonidine, should not be used. Carvedilol is the preferred beta blocker (combined alpha & beta blocker) in patients with heart failure with reduced ejection fraction⁴⁴. Other beta blockers indicated for use in heart failure are Bisoprolol, Metoprolol, Succinate and Nebivolol.

Antihypertensive treatment is commonly needed in patients with heart failure with preserved ejection fraction (HFpEF). The same BP threshold and target for drug treatment is indicated for HFrEF should be used. HFpEF patients commonly have multiple comorbidities that may adversely affect outcomes and complicate management^44,45.