• Arterial hypertension is defined as a blood pressure ≥ 140/90 mmHg.
• A normal, non-elevated blood pressure is < 120/70 mmHg.
• A blood pressure of 120–139/70–89 mmHg is also considered as an elevated blood pressure, but not arterial hypertension. Pharmacological treatment can also be considered at this blood pressure in patients with increased cardiovascular risk, for example, in patients with heart failure, coronary artery disease, renal insufficiency with a GFR ≤ 60 ml/min, microalbuminuria (uACR ≥ 30 mg/g), diabetes mellitus,...

High blood pressure can be either the cause of heart failure (hypertensive cardiomyopathy) or a precipitating factor for cardiac decompensation (acute heart failure) through the following mechanisms:

• Increased intracardiac pressure.
• Hypertrophy and stiffening of the left ventricle (LV).
• Dilation of the left atrium (LA).
• Increased risk of developing atrial fibrillation (AF).
• Increased risk of coronary atherosclerosis and myocardial infarction.

In addition, increased blood pressure potentially causes:

• Renal: glomerular hyperfiltration, proteinuria, glomerulosclerosis and progressive renal insufficiency.
• Arterial: endothelial dysfunction, fibrosis, stiffening, increased peripheral resistance, atherosclerosis,…
• Cerebral: ischemic or hemorrhagic TIA/CVA, white matter lesions, cerebral atrophy and cognitive decline (dementia),…
• Etc.

Good blood pressure control, maintaining a normal blood pressure, is therefore crucial for patients with heart failure. Treatment is recommended for a repeatedly confirmed blood pressure > 130/80 mmHg, with a target home blood pressure of 120–129/70–79 mmHg , provided the treatment is well tolerated and without hypotensive symptoms ( orthostatism , etc.).

The treatment goals and specific medications to be used do differ between patients with HFrEF / HFmrEF and those with HFpEF. In HFrEF / HFmrEF, the aim should be to titrate the treatment with the highest tolerated dose of neurohormonal blocking agents (ACE inhibitors/ARBs/ARNIs, beta-blockers, and MRAs, along with an SGLT-2 inhibitor) while maintaining a systolic blood pressure > 90 mmHg and without symptoms of hypotension. In HFpEF normotension around 120/80 mmHg is aimed for, with no specific target dose. Read below for more information.

To improve adherence, it's best to prescribe combination medications whenever possible, if available, rather than prescribing each medication separately. This is especially important when combining amlodipine and/or a thiazide diuretic with an ACE inhibitor or an ARB.

General lifestyle advice can help lower blood pressure in all patients:

• Low-salt diet.
• Weight loss, if applicable.
• Regular physical activity.

Goal:

• Optimal HFrEF therapy at the target dose or the maximum tolerated dose with a systolic blood pressure > 90 mmHg and without symptoms of dizziness on standing or walking around ( orthostatism ).
• In case of asymptomatic hypotension with a systolic blood pressure above 90 mmHg , no dose reduction of HFrEF therapy should be performed.

Treatment:

1. Pursuing optimal quadruple HFrEF therapy:

• • An ACE inhibitor (in case of intolerance due to irritating cough, switch to an ARB) or an ARNI ( angiotensin II receptor neprilysin inhibitor, valsartan - sacubitril ). These medications should always be uptitrated to the target dose or the maximum tolerated dose.
  • A beta blocker. These medications should always be uptitrated to the target dose or the maximum tolerated dose until a resting heart rate of around 60 beats per minute is reached.
  • A mineralocorticoid receptor antagonist (MRA): spironolactone 25-50 mg daily. In case of intolerance because of disturbing gynecomastia in men: switch to eplerenone.
  • An SGLT-2 inhibitor.

2. In the rare event that the systolic blood pressure is still > 130 mmHg, association of one of the following drugs may be considered:

• • Dihydropyridine calcium channel blockers such as amlodipine, lercanidipine, or felodipine. Note: these can cause peripheral edema without fluid retention or cardiac decompensation! In these cases, this therapy should be reduced or discontinued to avoid unnecessary diuretic therapy.
  • Thiazides or thiazide -like diuretics such as hydrochlorothiazide or indapamide. Note: these increase the risk of hyponatremia, hypokalemia, and gout.
  • Cedocard ( Isorbide dinitrate ) and/ or hydralazine (magistral).
  • Alpha-blockers. Preferred if urinary problems are also caused by prostatic hypertrophy.

Contraindicated

See also Medications to avoid.

• Non-dihydropyridine calcium channel blockers such as verapamil and diltiazem.
• Moxonidine and other centrally acting sympatholytics.

Goal:

• Normotension with an average blood pressure at home around 120/80 mmHg.
• In case of low blood pressure or symptoms of orthostatic hypotension, antihypertensive medication should be reduced. Hypotension should be avoided.

Treatment:

• As in other hypertensive patients without heart failure.
• Read also : HFpEF.
• Preference for:
  • An ACE inhibitor or an ARB. The combination of both is not recommended.
  • An MRA: spironolactone.
  • Dihydropyridine calcium channel blockers such as amlodipine, lercanidipine, or felodipine. Note: these can cause peripheral edema without fluid retention or cardiac decompensation! In these cases, this therapy should be reduced or discontinued to avoid unnecessary diuretic therapy.
  • Thiazides or thiazide -like diuretics such as hydrochlorothiazide or indapamide. Note: these increase the risk of hyponatremia, hypokalemia, and gout.
• In case of tachycardia due to e.g. AF: a beta-blocker and/or a non-dihydropyridine calcium channel blocker such as verapamil and diltiazem should be used.
• In case of insufficient effect, in case of severe renal impairment (making it impossible to prescribe or increase RAAS blockers) or in case of disturbing oedema (making it impossible to prescribe or increase calcium channel blockers) these medications can be considered:
  • Alpha blocker : terazosin 1 – 2 – 5 – 10 mg per day.
  • Moxonidine (centrally acting sympatholytic ).
  • Cedocard ( Isorbide dinitrate ) 3x 10 to 20 mg per day.
  • Hydralazine (magistral): 3 x 12.5 – 25 – 50 mg per day.

NB:

• Patients with HFpEF often also have chronotropic incompetence. Their heart rate does not increase sufficiently during exercise. This can sometimes be a contributing factor to a reduced exercise capacity. Therefore, beta blockers should be used in these patients primarily for supraventricular tachycardias. In other cases (for example, in patients who are still physically active), they are sometimes tapered or discontinued for persistent exercise intolerance and proven chronotropic incompetence during an exercise test.

• In mostly geriatric patients with frailty, orthostatic hypotension, or autonomic dysfunction (due to Parkinson's disease, diabetes mellitus, etc.), "permissive hypertension" may be considered. This involves a less stringent blood pressure management to prevent or reduce side effects (e.g., dizziness upon standing or walking, decreased mobility, falls with possible fractures, etc.). A systolic blood pressure of around 140 mmHg is acceptable in these patients. In the event of a symptomatic arterial hypertension flare-up, these patients can occasionally take an additional dose of an antihypertensive medication if needed, for example, rapid-release and short-acting Cedocard 5 mg sublingual tablets.