Recommendations for managing blood pressure in heart failure

Patient groupClassa
With hypertension at increased risk
< 130/80 mm Hg should be the optimal blood pressureI
With heart failure with reduced ejection fraction
Guideline-directed medical treatment titrated to attain a blood pressure of < 130/80 mm HgI
Nondihydropyridine calcium channel blockers not recommendedIII
With heart failure with preserved ejection fraction and symptoms of volume overload
Diuretics to control hypertensionI
With heart failure with preserved ejection fraction and persistent hypertension after management of volume overload
Guideline-directed medical therapy titrated to attain systolic blood pressure < 130 mm Hg. Although there are limited data to guide the choice of antihypertensive therapy in HFpEF, preferred agents include RAAS inhibition with ACE-I, ARB, and mineralocorticoid receptor antagonists (spironolactone).I
Nitrates not recommended in HFpEF, unless given for symptomatic coronary artery disease, due to association with a signal of harm or decreased exercise tolerance.III
  • a Class of recommendation (I strong, III no benefit).

  • ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; HFpEF = heart failure with preserved ejection fraction; RAAS = renin-angiotensin-aldosterone system

  • Information from reference 1.