Updated Guidelines on Hypertension and Heart Failure

In June, the Heart Failure Society of America (HFSA) published the 2010 Comprehensive Heart Failure Practice Guideline in the July issue of the Journal of Cardiac Failure, with a key focus on recommendations for hypertension and heart failure.

The management of heart failure (HF)—a syndrome characterized by high mortality, frequent hospitalization, poor quality of life, and multiple comorbidities—involves “both a multidimensional assessment process and a complex therapeutic regimen.” Because of the complex and changing picture of the condition and the accumulation of evidence-based therapy, clinicians cannot be expected to rely solely on personal experience and observation to guide therapeutic decisions.

According to HFSA, the situation has become exacerbated because HF is a chronic condition in most patients, and therefore, “the outcome of therapeutic decisions might not be apparent for several years.” In addition, “the natural history and prognosis of individual patients differs considerably, making it difficult to generalize.”

With all of these factors in mind—as well as the high prevalence of HF—HFSA leadership set out to update the guideline first developed several years ago that had “a narrow scope, concentrating on the pharmacologic treatment of chronic, symptomatic left ventricular dysfunction.” Not included in the original recommendations were subsets of the clinical syndrome of HF, such as acute decompensated HF and diastolic dysfunction, or issues around prevention.

Although a subsequent guideline was published in 2006 that addressed a range of topics including prevention, evaluation, disease management, and pharmacologic and device therapy for patients with HF, the new guidelines take it a step further by updating and expanding each of those areas, while adding a section on the Genetic Evaluation of Cardiomyopathy published separately in 2009.

Among the core topics addressed in the most recent guideline is hypertension. When the heart is functioning normally, vascular impedance is the primary determinant of blood pressure, according to the guideline. Therefore, pressure is a strong risk factor for development of left ventricular (LV) hypertrophy, increased myocardial oxygen consumption, coronary atherosclerosis, and subsequent HF, and “control of blood pressure in this setting is critical to prevent the development and progression of LV dysfunction.”

When LV function is impaired, however, the association between impedance and cardiac function becomes increasingly complex. Increases of impedance may impair LV emptying, and thus, not be reflected in a higher pressure. In this case, therapy is aimed at the impedance and not the blood pressure. And blood pressure may increase in response to effective therapy that improves LV emptying or reverses remodeling, even if the impedance is reduced.

The new recommendations are as follows, grouped into three primary categories:

Patients with Hypertension and Preserved Left Ventricular Ejection Fraction (LVEF) and Asymptomatic Left Ventricular Hypertrophy (LVH), or for Patients with Hypertension and HF with Preserved LVEF (Stage B):

• It is recommended that blood pressure be optimally treated to lower systolic and usually diastolic levels. More than 1 drug may be required. Target resting levels should be <130/<80 mm Hg, if tolerated.

Patients with Hypertension and Asymptomatic LV Dysfunction With LV Dilation and a Low LVEF:

• Prescription of an angiotensin converting enzyme (ACE) inhibitor (dose equivalent to 20 mg daily enalapril) is recommended.
• Addition of a beta blocker (dose equivalent to HF trials) is recommended even if blood pressure is controlled.
• If blood pressure remains >130/80 mm Hg then the addition of a thiazide diuretic is recommended, followed by a dihydropyridine calcium antagonist (eg, amlodipine or felodipine) or other antihypertensive drugs.

Patients with Hypertension and Symptomatic LV Dysfunction With LV Dilation and Low LVEF:

• Prescription of target doses of ACE inhibitors, angiotensin receptor blockers (ARBs), beta blockers, aldosterone inhibitors, and isosorbide dinitrate/hydralazine in various combinations (with a loop diuretic if needed) is recommended, based on doses used in large-scale outcome trials
• If blood pressure remains >130/80 mm Hg, a dihydropyridine calcium antagonist (eg, amlodipine or felodipine) may be considered or other antihypertensive medication doses increased.