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Treatment of hypertension in patients with heart failure

John D Bisognano, MD, PhD
Section Editors
George L Bakris, MD
Stephen S Gottlieb, MD
Norman M Kaplan, MD
Deputy Editor
John P Forman, MD, MSc


Hypertension is the most prevalent modifiable risk factor for the development of heart failure (HF) [1], both because hypertension increases cardiac work, which leads to the development of left ventricular hypertrophy (LVH), and because hypertension is a risk factor for the development of coronary heart disease. (See "Epidemiology and causes of heart failure".)

The incidence of HF in hypertensive patients varies according to the population and duration of follow-up. As an example, approximately 2 percent of high-risk hypertensive patients in the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial developed HF at three years [2]. Among the high-risk hypertensive population enrolled into the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), 1716 out of 32,804 participants developed HF during an average follow-up of nine years (5.4 percent) [3].

In contrast to the pattern seen in the general population, in which prognosis is poorer for hypertensive compared with normotensive individuals, a higher blood pressure prior to treatment is a predictor of better survival in patients with HF [4]. It is likely that this correlation is a consequence of the fact that more severe cardiac dysfunction causes a decline in systemic blood pressure, making low blood pressure a marker for more advanced HF [4]. This observation makes it difficult to study the benefits of antihypertensive therapy in this population.

Treatment of hypertension in patients with HF must take into account the type of HF that is present: systolic dysfunction, in which impaired cardiac contractility is the primary abnormality; or diastolic dysfunction, in which there is a limitation to diastolic filling and therefore in forward output due to increased ventricular stiffness [5]. (See "Treatment and prognosis of heart failure with preserved ejection fraction".)

The distinction between these two, not mutually exclusive types of HF can be made by assessment of left ventricular ejection fraction using echocardiography. (See "Determining the etiology and severity of heart failure or cardiomyopathy".)

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Literature review current through: Nov 2017. | This topic last updated: Jul 11, 2016.
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