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Treating Hypertension in Patients with Left Ventricular Dysfunction: Hitting the Fairway and Avoiding the Rough

Current Heart Failure Reports volume 10, pages 157–164 (2013)Cite this article

Abstract

Hypertension is a major risk factor in the development of heart failure (HF), yet current guidelines do not specify a target blood pressure (BP) for patients with established systolic or diastolic left ventricular (LV) dysfunction. While no randomized controlled trial (RCT) has been conducted to specify the optimal blood pressure in these patients, numerous trials have demonstrated the benefits of certain classes of medications and treatment strategies in patients with HF. Important factors to consider in treating hypertension in patients with HF include the type of HF (reduced vs. preserved ejection fraction), the etiology (ischemic vs. nonischemic), the severity of symptoms if any, the baseline blood pressure, as well as a wide variety of patient-specific factors. This paper reviews current evidence to address the question, “What should be the blood pressure goal in patients with asymptomatic and symptomatic left ventricular dysfunction?” We suggest a target blood pressure of 120–140/70–90 mm Hg in most cases, with lower pressures generally preferable if tolerated.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Perera GA. Hypertensive vascular disease; description and natural history. J Chron Dis. 1955;1:33–42.

    Article  PubMed  CAS  Google Scholar 

  2. Kannel WB, Castelli WP, McNamara PM, McKee PA, Feinleib M. Role of blood pressure in the development of congestive heart failure—the Framingham study. N Engl J Med. 1972;287:781–7.

    Article  PubMed  CAS  Google Scholar 

  3. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to congestive heart failure. JAMA. 275(20):1557–62.

  4. Hsia J, Margolis KL, Eaton CB, Wenger NK, Allison M, Wu L, et al. Prehypertension and cardiovascular disease risk in the Women’s Health Initiative. Circulation. 2007;115(7):855–60.

    Article  PubMed  Google Scholar 

  5. Psaty BM, Lumley T, Furberg CD, Schellenbaum G, Pahor M, Alderman MH, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA. 2003;289(19):2534–44.

    Article  PubMed  CAS  Google Scholar 

  6. Nigel S, Beckett NS, Ruth Peters R, Nigel S, Beckett NS, Ruth Peters R, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–98.

    Article  Google Scholar 

  7. Lee D, Floras J, Newton G, Austin P, Wang X, Liu P, et al. Association of blood pressure at hospital discharge with mortality in patients diagnosed with heart failure. Circ Heart Fail. 2009;2(6):616–23.

    Article  PubMed  Google Scholar 

  8. Muntwyler J, Abetel G, Gruner C, Follath F. One-year mortality among unselected outpatients with heart failure. Eur Heart J. 2002;23(23):1861–6.

    Article  PubMed  CAS  Google Scholar 

  9. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293.

    Article  Google Scholar 

  10. Pfeffer MA, Braunwald E, Moyé LA, The SAVE Investigators, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. N Engl J Med. 1992;327:669.

    Article  PubMed  CAS  Google Scholar 

  11. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999; 353:2001.

    Google Scholar 

  12. Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet. 2003;362(9386):759–66.

    Article  PubMed  CAS  Google Scholar 

  13. Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003;362(9377):7–13.

    Article  PubMed  CAS  Google Scholar 

  14. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991;325:303.

    Article  PubMed  CAS  Google Scholar 

  15. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341:709.

    Article  PubMed  CAS  Google Scholar 

  16. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309.

    Article  PubMed  CAS  Google Scholar 

  17. •• Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364:11. In this randomized trial of patients with HFrEF with NYHA class II symptoms, the addition of eplerenone to standard therapy reduced mortality by 24%, and reduced hospitalization for HF by 42%.

    Article  PubMed  CAS  Google Scholar 

  18. Diez J, Fortuna MA, Ravassa S. Apoptosis in hypertensive heart disease. Curr Opin Cardiol. 1998;13:317–25.

    Article  PubMed  CAS  Google Scholar 

  19. Drazner MH, Rame JE, Marino EK, Gottdiener JS, Kitzman DW, Gardin JM, et al. Increased left ventricular mass is a risk factor for the development of a depressed left ventricular ejection fraction within five years: the Cardiovascular Health Study. J Am Coll Cardiol. 2004;43:2207–15.

    Article  PubMed  Google Scholar 

  20. Shapiro BP, Owan TE, Mohammed S, Kruger M, Linke WA, Burnett JC, et al. Mineralocorticoid signaling in transition to heart failure with normal ejection fraction. Hypertension. 2008;51:289–95.

    Article  PubMed  CAS  Google Scholar 

  21. Ahmed SH, Clark LL, Pennington WR, Webb CS, Bonnema DD, Leonardi AH, et al. Matrix metalloproteinases/tissue inhibitors of metalloproteinases: relationship between changes in proteolytic determinants of matrix composition and structure, functional, and clinical manifestations of hypertensive heart disease. Circulation. 2006;113:2089–96.

    Article  PubMed  CAS  Google Scholar 

  22. Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation. 2008;118:1433–41.

    Article  PubMed  Google Scholar 

  23. Melenovsky V, Borlaug BA, Rosen B, Hay I, Ferruci L, Morell CH, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol. 2007;49(2):198–207. Epub 2006 Dec 29.

    Article  PubMed  Google Scholar 

  24. Lam CS, Roger VL, Rodeheffer RJ, Bursi F, Borlaug BA, Ommen SR, et al. Cardiac structure and ventricular-vascular function in persons with heart failure and preserved ejection fraction from Olmsted County, Minnesota. Circulation. 2007;115(15):1982–90.

    Article  PubMed  Google Scholar 

  25. Borlaug BA, Lam CS, Roger VL, Rodeheffer RJ, Redfield MM. Contractility and ventricular systolic stiffening in hypertensive heart disease insights into the pathogenesis of heart failure with preserved ejection fraction. J Am Coll Cardiol. 2009;54(5):410–8.

    Article  PubMed  Google Scholar 

  26. Moser M, Hebert PR. Prevention of disease progression, left ventricular hypertrophy and congestive heart failure in hypertension treatment trials. J Am Coll Cardiol. 1996;27(5):1214–8.

    Article  PubMed  CAS  Google Scholar 

  27. Greenberg B, Quinones MA, Koilpillai C, Limacher M, Shindler D, Benedict C, et al. Effects of long-term enalapril therapy on cardiac structure and function in patients with left ventricular dysfunction. Results of the SOLVD echocardiography substudy. Circulation. 1995;91(10):2573–81.

    Article  PubMed  CAS  Google Scholar 

  28. Longobardi G, Ferrara N, Furgi G, Abete P, Rengo F. Improvement of myocardial blood flow to ischemic regions by angiotensin-converting enzyme inhibition. J Am Coll Cardiol. 2000;36(4):1437–8.

    Article  PubMed  CAS  Google Scholar 

  29. Minai K, Matsumoto T, Horie H, Ohira N, Takashima H, Yokohama H, et al. Bradykinin stimulates the release of tissue plasminogen activator in human coronary circulation: effects of angiotensin-converting enzyme inhibitors. J Am Coll Cardiol. 2001;37(6):1565–70.

    Article  PubMed  CAS  Google Scholar 

  30. Packer M, Poole-Wilson PA, Armstrong PW, Cleland JG, Horowitz JD, Massie BM, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation. 1999;100(23):2312–8.

    Article  PubMed  CAS  Google Scholar 

  31. Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349(20):1893–906.

    Article  PubMed  CAS  Google Scholar 

  32. Weir RA, McMurray JJ, Puu M, Solomon SD, Olofsson B, Granger CB, et al. Efficacy and tolerability of adding an angiotensin receptor blocker in patients with heart failure already receiving an angiotensin-converting inhibitor plus aldosterone antagonist, with or without a beta blocker. Findings from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM)-Added trial. Eur J Heart Fail. 2008;10(2):157–63.

    Article  PubMed  CAS  Google Scholar 

  33. Cohn JN, Pfeffer MA, Rouleau J, Sharpe N, Swedberg K, Straub M, et al. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail. 2003;5(5):659–67.

    Article  PubMed  CAS  Google Scholar 

  34. ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs. chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA. 2000;283(15):1967–75.

    Article  Google Scholar 

  35. U.S. Food and Drug Administration. Aliskiren-containing medications: Drug safety communication—new warning and contraindication. 2012.

  36. Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362(9386):777–81.

    Article  PubMed  CAS  Google Scholar 

  37. Solomon SD, Janardhanan R, Verma A, Bourgoun M, Daley WL, Purkayastha D, et al. Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial. Lancet. 2007;369(9579):2079–87.

    Article  PubMed  CAS  Google Scholar 

  38. Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, Zile MR, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359(23):2456–67.

    Article  PubMed  CAS  Google Scholar 

  39. • Solomon SD, Verma A, Desai A, Hassanein A, Izzo J, Oparil S, et al. Effect of intensive versus standard blood pressure lowering on diastolic function in patients with uncontrolled hypertension and diastolic dysfunction. Hypertension. 2010;55(2):241–8. In this randomized trial of patients with HFpEF and uncontrolled hypertension, improvements in diastolic function as measured by echocardiographic parameters correlated with the degree of blood pressure reduction achieved.

    Article  PubMed  CAS  Google Scholar 

  40. Phillips RA, Goldman ME, Ardeljan M, Arora R, Eison HB, Yu BY, et al. Determinants of abnormal left ventricular filling in early hypertension. J Am Coll Cardiol. 1989;14(4):979–85.

    Article  PubMed  CAS  Google Scholar 

  41. Hunt SA, Abraham WT, Chin MH, et al. Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119:e391.

    Article  PubMed  Google Scholar 

  42. Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: a randomized controlled trial. J Am Coll Cardiol. 2012;60(16):1521–8.

    Article  PubMed  Google Scholar 

  43. O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439–50.

    Article  PubMed  Google Scholar 

  44. • Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Böhm M, et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376(9756):1903–9. In this landmark, randomized trial in patients with resistant hypertension, catheter-based renal denervation therapy resulted in a reduction in blood pressure of 32/12 mmHg at 6 months, with no significant complication or adverse event.

    Article  PubMed  Google Scholar 

  45. • Brandt MC, Mahfoud F, Reda S, Schirmer SH, Erdmann E, Böhm M, et al. Renal sympathetic denervation reduces left ventricular hypertrophy and improves cardiac function in patients with resistant hypertension. J Am Coll Cardiol. 2012;59(10):901–9. In patients with resistant hypertension, LVH, and diastolic dysfunction treated with catheter-based renal denervation therapy, this study demonstrated significant reduction in LVH and improvement in diastolic function based on echocardiographic parameters.

    Article  PubMed  Google Scholar 

  46. Fagard RH, Staessen JA, Thijs L, Celis H, Bulpitt CJ, de Leeuw PW, et al. On-treatment diastolic blood pressure and prognosis in systolic hypertension. Arch Intern Med. 2007;167(17):1884–91.

    Article  PubMed  Google Scholar 

  47. Rosendorff C et al. Treatment of hypertension in the prevention and management of ischemic heart disease. Circulation. 2007;115:2761–88.

    Article  PubMed  Google Scholar 

  48. Pepine CJ et al. A calcium antagonist vs a non–calcium antagonist hypertension treatment strategy for patients with coronary artery disease: the International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA. 2003;290:2805–16.

    Article  PubMed  CAS  Google Scholar 

  49. • Anderson JL et al. ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non–ST-Elevation Myocardial Infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 123. 2011. This update to ACC-AHA guidelines suggests a blood pressure goal of <140/90 mmHg for based on JNC-7, and <130/80 mmHg for patients with diabetes or chronic kidney disease.

  50. Bangalore S et al. Pulse pressure and risk of cardiovascular outcomes in patients with hypertension and coronary artery disease: an International VErapamil SR-trandolapril Study (INVEST) analysis. Eur Heart J. 2009;30:1395–401.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Samuel W. Joffe declares he has no conflict of interest.

Robert A. Phillips declares he has no conflict of interest.

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Authors and Affiliations

  1. University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA

    Samuel W. Joffe & Robert A. Phillips

  2. Heart and Vascular Center of Excellence, UMass Memorial Medical Center, Worcester, MA, USA

    Robert A. Phillips

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  1. Samuel W. Joffe
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  2. Robert A. Phillips
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Correspondence to Samuel W. Joffe.

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Joffe, S.W., Phillips, R.A. Treating Hypertension in Patients with Left Ventricular Dysfunction: Hitting the Fairway and Avoiding the Rough. Curr Heart Fail Rep 10, 157–164 (2013). https://doi.org/10.1007/s11897-013-0137-9

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  • DOI: https://doi.org/10.1007/s11897-013-0137-9

Keywords

  • Hypertension
  • Heart failure
  • Ventricular dysfunction
  • Systolic function
  • Diastolic function
  • Angiotensin converting enzyme inhibitor
  • Angiotensin receptor blocker
  • Beta blocker
  • Aldosterone antagonist
  • Diuretic