Download The management of co-morbidities in patients with heart failure

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The management of co-morbidities in patients with heart failure - 4 Hypertension
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BACKGROUND
The 2016 ESC/HFA HF guidelines carry an important section on the treatments of co-morbidities
in HF.[1] Foremost of these in terms of frequency and its relevance to the aetiology of HF, especially
HFpEF is hypertension.
In this chapter we will review what the recent guidelines say about the
management of hypertension in the setting of HF, both HFrEF and HFpEF and expand on some of the
practical advice.
These guidelines carry an extremely important guidance table (reproduced in figure 1). This table
carries an enormous amount of important advice, for it outlines the progressive steps in using evidencebased medicines to manage the hypertensive HF patient, in which order to try agents and how to
progressively increase the drug treatment armamentarium used. It also summarises in a colour and
alphanumeric schema the strength of the recommendation and the strength of the underlying evidence,
and then in addition it importantly points pout those otherwise widely used agents which should NOT be
used in the setting of HF where they would form part of any conventional hypertension guidelines for
patients not having co-morbid heart failure. It therefore deserves a much closer look.
FIGURE 1 NEAR HERE
In the preamble to this guidance table it is pointed out that hypertension is a potent risk factor for
HF (and for HFpEF even more than for HFrEF); that antihypertensive therapy markedly reduces the
incidence of HF and that although good control of high blood pressure is essential in all HF patients, poor
control in advanced HFrEF is actually extremely uncommon, whereas it is a much more important
problem in milder HFrEF cases and in HFmrEF and HFpEF in particular. HF has not been a prominent
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end-point in many hypertension trials. Despite this there is a consistent and powerful protection from HF
that can be achieved by treating hypertension that appears related to the BP control rather ta the choice of
agent, with the sole exception that alpha-adrenoceptor blockers being less effective than other drug
classes in this effect. [2] Good BP control is an essential part of the management of the HF patients with
prospective observations showing in HF patients followed long term, higher baseline systolic, diastolic
and pulse pressure levels were associated with higher rates of adverse events. [3]
The steps to good BP control in Heart Failure.
Step 1 in any hypertensive HF patient is to use an ACE inhibitor (or ARB only if such is not tolerated), a
beta blocker and an MRA. Clinical trials evaluating goal blood pressure reduction in patients with HFrEF
and concomitant hypertension have not been done yet. According to 2013 ESH/ESC Guidelines for the
management of arterial hypertension BP targets are the same as in the non-HF hypertensive patient
(140/90 by repeated office BP measurement in most, between 140-150 in elderly with starting SBP’s
>160mmHg) with a lower DBP target for diabetics (85 mmHg).[4] However, the recently published data
from the SPRINT trial [5, 6] allowed discussing the possibility of the achievement of lower systolic blood
pressure (< 130 mm Hg) in patients with HFrEF and hypertension, as it was mentioned in 2017
ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart
Failure [7].
As anyone with significant HF will already be recommended a beta blocker an ACEI and a MRA there is
really little of clinical change to make here, the main difference being the prominent position of betablockade as opposed to this drug class’s relative demotion in non-HF hypertension guidelines. Step 2,
should greater BP control be needed after the drugs is step one have all been started and up-titrated is to
commence a thiazide diuretic (or if the patient is treated with a thiazide diuretic, switching to a loop
diuretic). Care will need to be taken if already on loop diuretics for HF as combination diuretics can cause
severe fluid depletion, renal impairment and electrolyte disturbances. Step 3 (which will rarely be needed
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in moderate to severe HFrEF) is to add a calcium channel blocker, but here the choice of agent is critical.
Amlodipine and to a lesser extent Felodipine have been shown to be safe in HFrEF.[8,9] If an alternative
is needed hydralazine can be added (but should not be sued without the ACEi and beta blockers of the
earlier steps).[10]
Importantly advice is given in which drugs should never be used in the setting of HF (despite being
hypertension guidelines).
These include Moxonidine, alpha receptor antagonists, diltiazem and
verapamil, although the latter two are probably safe in HFpEF, because the concern in HFrEF is their
negative inotropic effect which is of less concern in true HFpEF. Moxonidine increased mortality in
patients in the MOXCON trial in HFrEF[11] and there are concerns of the risk in HFrEF patients of
neurohormonal activation, fluid retention and worsening HF with alpha-adrenoceptor antagonists.[12-14]
Lastly in the setting of acute heart failure (AHF) i.v. nitrates (or sodium nitroprusside, starting with 0.3
μg/kg/min and increasing up to 5 μg/kg/min) are recommended to lower blood pressure. For AHF with
uncontrolled hypertension (mostly HFpEF rather than HFrEF) Isosorbide dinitrate infusion is
recommended starting with1 mg/h, increasing up to 10 mg/h.
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REFERENCES
1. Ponikowski P, Voors A, Anker S et al The Task Force for the diagnosis and treatment of acute and
chronic heart failure of the European Society of Cardiology (ESC). 2016 ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure. European Journal of Heart Failure.
Published online 26 May 2016
2. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone.
ALLHAT Collaborative Research Group. JAMA 2000;283: 1967 – 1975.
3. Lip GYH, Skjøth F, Overvad K, Rasmussen LH, Larsen TB. Blood pressure and prognosis in patients
with incident heart failure: the Diet, Cancer and Health (DCH) cohort study. Clin Res Cardiol
2015;104:1088 – 1096.
4. Giuseppe Mancia, Robert Fagard, Krzysztof Narkiewicz, et al. 2013 ESH/ESC Guidelines for the
management of arterial hypertension European Heart Journal 2013;34:2159 – 2219 DOI:
http://dx.doi.org/10.1093/eurheartj/eht151
5. Wright JT Jr, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard
Blood-Pressure Control. N. Engl. J Med. 2015; 373:2103-16.
6. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs. standard blood pressure control and
cardiovascular disease outcomes in adults aged >/=75 years: A randomized clinical trial. JAMA. 2016;
315:2673-82.
7. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS,
Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN,
Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline
for the Management of Heart Failure: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of
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Wertheimer JH, Cropp AB, DeMets DL. Effect of amlodipine on morbidity and mortality in severe
chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group. N Engl J
Med 1996;335:1107–1114.
9. Cohn JN, Ziesche S, Smith R, Anand I, Dunkman WB, Loeb H, Cintron G, Boden W, Baruch L, Rochin P,
Loss L. Effect of the calcium antagonist felodipine as supplementary vasodilator therapy in patients
with chronic heart failure treated with enalapril: V-HeFT III. Vasodilator-Heart Failure Trial (V-HeFT)
Study Group. Circulation 1997;96:856–863.
10. Taylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M,
Worcel M, Cohn JN. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure.
N Engl J Med 2004;351:2049–2057.
11. Cohn JN, Pfeffer MA, Rouleau J, Sharpe N, Swedberg K, Straub M, Wiltse C, Wright TJ, MOXCON
Investigators. Adverse mortality effect of central sympathetic inhibition with sustained-release
moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail 2003;5:659–667.
12. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major
Cardiovascular Events in Hypertensive Patients Randomized to Doxazosin vs Chlorthalidone. JAMA J
Am Med Assoc 2000;283:1967–1975.
13. Dorszewski A, Göhmann E, Dorsźewski B, Werner GS, Kreuzer H, Figulla HR. Vasodilation by urapidil
in the treatment of chronic congestive heart failure in addition to angiotensin-converting enzyme
inhibitors is not beneficial: results of a placebo-controlled, double-blind study. J Card Fail 1997;3:91–
96.
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14. Bayliss J, Norell MS, Canepa-Anson R, Reid C, Poole-Wilson P, Sutton G. Clinical importance of the
renin-angiotensin system in chronic heart failure: double blind comparison of captopril and prazosin.
Br Med J (Clin Res Ed) 1985;290:1861–1865.
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Figures:
Figure 1: The 2016 ESC/HFA guidelines (ref 1) guidance for the management of hypertension
complicating heart failure.