Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association

HomeCirculationVol. 134, No. 23Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBContributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association Biykem Bozkurt, MD, PhD, FAHA, Chair, David Aguilar, MD, FAHA, Anita Deswal, MD, MPH, FAHA, Sandra B. Dunbar, RN, PhD, FAHA, Gary S. Francis, MD, FAHA, Tamara Horwich, MD, MS, FAHA, Mariell Jessup, MD, FAHA, Mikhail Kosiborod, MD, FAHA, Allison M. Pritchett, MD, Kumudha Ramasubbu, MD, Clive Rosendorff, MD, PhD, DScMed, FAHA and Clyde Yancy, MD, MSc, FAHAOn behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; Council on Hypertension; and Council on Quality and Outcomes Research Biykem BozkurtBiykem Bozkurt Search for more papers by this author , David AguilarDavid Aguilar Search for more papers by this author , Anita DeswalAnita Deswal Search for more papers by this author , Sandra B. DunbarSandra B. Dunbar Search for more papers by this author , Gary S. FrancisGary S. Francis Search for more papers by this author , Tamara HorwichTamara Horwich Search for more papers by this author , Mariell JessupMariell Jessup Search for more papers by this author , Mikhail KosiborodMikhail Kosiborod Search for more papers by this author , Allison M. PritchettAllison M. Pritchett Search for more papers by this author , Kumudha RamasubbuKumudha Ramasubbu Search for more papers by this author , Clive RosendorffClive Rosendorff Search for more papers by this author and Clyde YancyClyde Yancy Search for more papers by this author and On behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; Council on Hypertension; and Council on Quality and Outcomes Research Originally published31 Oct 2016https://doi.org/10.1161/CIR.0000000000000450Circulation. 2016;134:e535–e578Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 IntroductionThe comorbidities of hypertension, diabetes mellitus, obesity, hyperlipidemia, and metabolic syndrome are common in patients with heart failure (HF) and affect clinical outcomes.1–3 Interestingly, although these comorbidities are associated with the development of incident HF in the general population, in patients with established HF, their contributory roles to clinical outcomes are not predictable, and their management is quite challenging. Recent American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines have addressed the role of lifestyle modification,4 treatment of blood cholesterol,5 and management of overweight and obesity6 in the general population and in patients with increased cardiovascular risk, and a recent report from the Eighth Joint National Committee addressed the management of hypertension.7 However, these guidelines did not specifically address the management of such comorbidities in patients with HF. Similarly, the most recent ACCF/AHA HF practice guidelines8 in 2013 addressed the overall management of comorbidities in patients with HF in broad terms, but again, specific and detailed recommendations on how to manage hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome are lacking. The intent of this AHA scientific statement is to summarize data relevant to contributory risk and to provide guidance on the management of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in the development and prognosis of HF to provide recommendations (Table 1) and to foster communication between physicians and other healthcare professionals and patients on the management of these comorbidities. Recommendations in this document are based on published studies and the multidisciplinary expertise of the writing group and harmonized with published practice guidelines from the ACC/AHA4–6,8–12 and other organizations.7,13–15Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceHypertension and HFHypertension is a worldwide epidemic; in many countries, 50% of the population >60 years of age has hypertension. Hypertension is defined as a repeatedly elevated blood pressure (BP) exceeding 140/90 mm Hg. The prevalence of hypertension is steadily increasing, even with the expanded use of antihypertensive medications.16 It is widely recognized that hypertension is associated with increased cardiovascular and all-cause mortality independently of other risk factors.14,17 Specific HF mortality attributable to hypertension is probably underreported because of the competing adjudication for stroke or myocardial infarction (MI) at the end of the spectrum of hypertensive cardiovascular death.Hypertension Plays a Significant Role in the Development of HFElevated levels of diastolic BP and especially systolic BP (SBP) are major risk factors for the development of HF.18,19 One of the most impactful observations from the Framingham cohort was that the cumulative incidence of HF was significantly higher in patients with hypertension18,19 (Figure 1) Among 5143 patients, 91% of the patients with HF had hypertension antedating the development of HF, underlining that in the majority of patients with HF, hypertension was a contributing cause. The hazard ratios (HRs) for developing HF in hypertensives compared with normotensives were 2-fold higher in men and 3-fold higher in women.18,19 It should be noted that the risk associated with hypertension may be accentuated through its confounding effect on ischemic heart disease and other cardiovascular outcomes such as stroke. Furthermore, these studies predate current HF management strategies and guidelines and may no longer reflect the risk in the current population treated for hypertension. However, they underscore the importance of hypertension as a cause of HF when left untreated. The residual lifetime risk for hypertension for middle-aged and elderly individuals in the United States is 90%, indicating a huge public health burden20 and defining the importance of strategies to control hypertension to prevent HF.Download figureDownload PowerPointFigure 1. Cumulative incidence of heart failure, adjusted for death as a competing risk, by baseline systolic blood pressure (SBP) categories of <120, 120 to 139, 140 to 159, and ≥160 mm Hg for women (top), men (middle), and the overall population (bottom). Reprinted from Butler et al19 with permission with permission from BMJ Publishing Group Ltd. Copyright © 2011, BMJ Publishing Group Ltd and the British Cardiovascular Society.Treatment of Hypertension Prevents the Development of HFLong-term treatment of both systolic and diastolic hypertension has been shown to reduce the risk of HF.21,22 With treatment of hypertension, the risk of developing HF is reduced by 30% in younger populations,23 by 50% in the elderly,22,24 and by almost 80% among the elderly with history of MI.22 A meta-analysis of long-term hypertension treatment trials25 and a number of large, controlled studies26 have uniformly demonstrated that optimal BP control decreases the risk of new HF by ≈50%. In placebo-controlled trials, although the relative risks of total major cardiovascular events were reduced by regimens based on angiotensin-converting enzyme (ACE) inhibitors (22%) or calcium antagonists (18%), the risk for developing HF was reduced significantly by ACE inhibitors but not calcium antagonists.27 Greater risk reductions were produced by treatment regimens that targeted lower BP goals than those targeting relatively higher BP goals.28TreatmentTreatment of Hypertension in Patients at Risk for Developing HFGoals of Treatment of Hypertension to Prevent HFPatients with hypertension are at high risk for developing HF (stage A), and their BP should be controlled in accordance with contemporary guidelines to lower the risk of HF (Level of Evidence A8; Table 2). According to the recently published 2014 evidence-based guidelines for the management of high BP in adults,7 the goal for treatment of BP has been identified as <140/90 mm Hg for patients who are <60 years of age or for adult patients with chronic kidney disease or diabetes mellitus and as <150/90 mm Hg for patients ≥60 years of age in the general population. It should be noted that this last recommendation of a higher target for patients ≥60 years of age has been controversial and debated in the literature.32–34 There is evidence that the initiation of antihypertensive treatment for the above thresholds is associated with a reduction of HF and other cardiovascular events and overall mortality among hypertensive adults ≥30 years of age in the general population or in hypertensive patients ≥18 years of age with chronic kidney disease or diabetes mellitus.7 Similar targets were quoted in the 2002 “AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke,” which identified a general goal of <140/90 mm Hg for the treatment of hypertension in HF.9 Ongoing trials are intended to specifically address the question of goal BP reduction, and a new ACCF/AHA Guideline Writing Committee has been convened to address the management of hypertension.Table 2. Recommendation for the Treatment of Hypertension in Stage A HF: Asymptomatic Patients at Risk for HFRecommendationCORLOEReferenced GuidelineReferencesHypertension should be controlled in accordance with contemporary guidelines to lower the risk of development of HF.IA7–914, 21–28, 30, 31COR indicates Class of Recommendation; HF, heart failure; and LOE, Level of Evidence.Medication Choices for the Treatment of Hypertension to Prevent HFFor antihypertensive regimens in patients without established HF, optimal control of BP should remain the primary goal. The most recent 2014 evidence-based guideline for the management of high BP in adults recommends that in the general nonblack population, including those with diabetes mellitus, the initial antihypertensive treatment should include a thiazide-type diuretic, a calcium channel blocker, an ACE inhibitor, or an angiotensin receptor blocker (ARB).7 Each of these 4 drug classes recommended by the writing group yielded comparable effects on overall mortality, cardiovascular (excluding HF), cerebrovascular, and kidney outcomes. However, the effects of these drug classes on HF differ.Treatment with a thiazide-type diuretic or an ACE inhibitor has been shown to be more effective than treatment with a calcium channel blocker in improving HF outcomes.7 Although the writing committee recognized that improved HF outcome was an important finding that should be considered in the selection of a drug for initial therapy for hypertension, the panel did not conclude that it was compelling enough to preclude the use of the other drug classes for initial therapy. The panel also acknowledged that the evidence supported BP control, rather than a specific agent used to achieve that control, as the most relevant consideration for their recommendation.7 Supporting this, historically, most antihypertensive drugs have demonstrated comparable cardiovascular efficacy and safety.35 Specifically, diuretic-based antihypertensive therapies have been shown to prevent HF in a wide range of target populations as first-line therapy.27,35–39 Additionally, low-dose diuretics have been shown to be more effective as a first-line treatment for preventing the development of HF compared with ACE inhibitors, β-blockers, or calcium channel blockers by meta-analysis.38 It should also be noted that most of the original trials used the longer-acting chlorthalidone rather than hydrochlorothiazide. ACE inhibitors have also been shown to be very effective in the prevention of HF,14,27,35,40 even more significantly in patients with left ventricular (LV) systolic dysfunction or patients after MI.41,42 Likewise, ARBs have been shown to reduce the incidence of HF, especially in patients with hypertension and type 2 diabetes mellitus and nephropathy.43,44 However, calcium channel blockers appear to be somewhat less efficacious than the above agents for preventing HF.8,27 There are inadequate data to determine whether this is true only for dihydropyridine calcium channel blockers or whether it is true of the entire class of drugs.26 Regarding α-blockers, in the ALLHAT trial (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial), doxazosin was inferior to chlorthalidone for the prevention of HF and was associated with the doubling of HF risk compared with chlorthalidone.45,46 The “2013 ACCF/AHA Guideline for the Management of Heart Failure” indicated that the role of calcium antagonists or α-blockers is less clear for reducing the risk for incident HF, and the choice of antihypertensive therapy should follow the contemporary guidelines.8 In addition to medications, patients with hypertension should be advised on healthy lifestyle modification; weight reduction; reduction of sodium intake; increased consumption of fruits, vegetables, and low-fat dairy products; and moderation of alcohol intake.7,9,14In patients with stage B HF with structural heart disease or LV dysfunction but without HF symptoms, there is benefit with ACE inhibitors, ARBs, or β-blockers (Table 3). Thus, in patients with a recent or remote history of MI or acute coronary syndrome and reduced ejection fraction (EF), ACE inhibitors49–51 (or ARBs if the patient is ACE inhibitor intolerant30,52) prevent symptomatic HF and reduce mortality. Similarly, in patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, β-blockers reduce mortality.53–55 In patients with a reduced EF but without any history of MI or symptoms of HF, ACE inhibitors prevent symptomatic HF,51,56 and β- blockers can improve symptoms, ameliorate LV remodeling, and improve LV function.57,58 Although these beneficial effects of ACE inhibitors, ARBs, and β-blockers are not specific for patients with hypertension or for treatment of BP, a significant proportion of patients in these trials (40%–60%) had a history of hypertension, and the beneficial effects could be generalized to the hypertensive population.Table 3. Recommendations for the Treatment of Hypertension in Stage B HF: Patients With Cardiac Structural Abnormalities or Remodeling Who Have Not Developed HF SymptomsRecommendationsCORLOEReferenced GuidelineReferencesIn patients with structural cardiac abnormalities, including LV hypertrophy, BP should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF.IA7–9, 2914, 22, 31, 35, 47Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF. α-Adrenergic blockers such as doxazosin should be avoided and might be used only if other drugs for the management of hypertension and HF are inadequate to achieve BP control at maximum tolerated doses.III: HarmC8, 29, 4846ACE indicates angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; BP, blood pressure; COR, Class of Recommendation; HF, heart failure; LOE, Level of Evidence; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.Treatment of Hypertension in Patients With Established HFHow Aggressively to Treat BP in Patients With HF?There have not been compelling data to justify a single BP target in treating hypertension in patients with established HF. Former guidelines and position papers differ significantly in such threshold definitions and lack strong evidence for treatment targets of hypertension in HF.9,14,48,59 Therefore, the optimal BP target for the treatment of hypertension in patients with HF is not firmly established. The 2007 AHA scientific statement on the treatment of hypertension in the prevention and management of ischemic heart disease recommended a target BP of <130/80 mm Hg in patients with HF.48 Similarly, the 2002 “AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke”9 identified the BP treatment goal as <130/85 mm Hg if HF was present. However, these recommendations were empirical, not supported by trial evidence.9,48 Furthermore, there is concern about potential adverse outcomes with BP lowering that is too aggressive, which was further supported by the change to a higher BP threshold of 140/90 mm Hg in patients <60 years of age and <150/90 mm Hg in patients ≥60 years of age in the 2014 evidence-based guideline for the management of high BP in adults.7 It should be noted, however, that the writing committee did not address BP treatment targets in patients with established HF. The lack of definitive BP targets in patients with existing HF notwithstanding, treatment of HF is usually the main focus of the initial treatment of patients with established HF, and the standard treatment of HF usually lowers BP. This is supported by the observation that SBP has usually been lowered to a normal range of 110 to 130 mm Hg in most successful HF treatment trials with HF medications.48 After optimization of HF treatment, if BP is not controlled, further treatment strategies targeting both BP and HF can be used. It should also be noted that the BP-lowering effects of HF medications may relate to the baseline BP; that is, there may be a greater BP-lowering effect in patients with a higher baseline BP. However, the beneficial effects of the HF medications are usually independent of the baseline BP or changes in BP and do not vary according to baseline BP or reductions in SBP levels.60–62Medication Choices for the Treatment of Hypertension in Patients With HFCurrently, there are no randomized, large-scale trials comparing the effectiveness of different antihypertensive medications targeting optimal treatment of BP solely in patients with hypertension and established HF. Thus, most evidence comes from hypertension clinical trials that have not excluded patients with a history of HF. In patients with established HF, drugs that have been shown to improve outcomes for patients with HF generally also lower BP. Thus, the emphasis should be on initiating and optimizing guideline-directed medical treatment of HF, which will likely help control BP at target doses. Therefore, patients with hypertension and HF with reduced EF (HFrEF) are treated with diuretics, ACE inhibitors (or ARBs if ACE inhibitor intolerant), β-blockers, and aldosterone antagonists unless contraindicated8 (Table 4).Table 4. Recommendations for the Treatment of Hypertension in Stage C HF: Patients With Cardiac Structural Abnormalities or Remodeling With Prior or Current Symptoms of HFRecommendationsCORLOEReferenced GuidelineReferencesPatients with previous or current symptoms of HFrEF should be treated with GDMT, including diuretics, ACE inhibitors (or ARBs if ACE inhibitor intolerant), β-blockers, and aldosterone receptor antagonists, which have been proven to improve outcomes for patients with HF and can lower BP in hypertensive patients with HFrEF.IA for clinical outcomes, B for BP control8, 2950, 63–68Addition of hydralazine/isosorbide dinitrate to the background treatment with ACE inhibitor or ARB and β-blocker in self-described black patients with HFrEF and persistent NYHA class III or IV HF symptoms is beneficial to reduce morbidity and mortality and can lower BP in hypertensive patients with HFrEF.IA for reduction in morbidity and mortality in HF, B for BP control8, 2969, 70The treatment of hypertension in patients with HF should include behavioral modification such as sodium restriction and a closely monitored exercise program. Weight reduction in overweight or obese, an appropriate diet, and moderation of alcohol intake are recommended in patients with hypertension.IC7, 9, 14, 48Thiazide or thiazide-like diuretics can be useful for BP control and to reverse mild volume overload and associated symptoms in symptomatic patients with HF with volume overload. Loop diuretics, which are the preferred agents for treatment of congestion in symptomatic patients with HF, are less effective than thiazide or thiazide-like diuretics in lowering BP.IIaC7, 8, 48Addition of hydralazine isosorbide to the background therapy with ACE inhibitor or ARB and β-blocker may be beneficial for BP control in nonblack patients with HFrEF and hypertension.IIaC871Drugs to avoid in patients with HF and hypertension include nondihydropyridine calcium channel blockers (eg, verapamil and diltiazem) and moxonidine. An attempt should be made to avoid α-adrenergic blockers such as doxazosin; they might be used only if other drugs for the management of hypertension and HF are inadequate to achieve BP control at maximum tolerated doses.III: HarmC8, 14, 29, 48ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; COR, Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; and NYHA, New York Heart Association.Although thiazide or thiazide-like diuretics are usually recommended for the treatment of hypertension,7 in patients with current or prior symptoms of HF who have evidence of fluid retention, loop diuretics are usually used8 (Table 4). It should be noted, however, that loop diuretics are usually less effective than thiazide or thiazide-like diuretics in lowering BP8 and thus should be used for the management of hypertension in patients with symptomatic HF with congestion. For patients with stage C HFrEF, ACE inhibitors (or ARBs in ACE inhibitor–intolerant patients), β-blockers, and aldosterone antagonists are titrated to target doses as tolerated. BP is frequently within the target range or lower after careful titration of these agents. In those for whom BP remains in the hypertensive range, further increases of the recommended agents may be considered. Reasonable next steps would be the addition of other medications with proven benefit in HF populations such as ARBs or aldosterone antagonists or the addition of nitrates or hydralazine.Treatment of Refractory Hypertension in HFMost patients with advanced stage C or D HF do not manifest hypertension and may actually develop hypotension resulting from pump failure and an inability to raise the BP. However, if a patient with HFrEF has refractory hypertension, there are no definitive studies to provide guidance on the efficacy and safety of additional antihypertensive approaches when recommended HF therapies are inadequate to treat BP. Nondihydropyridine calcium channel blockers (diltiazem, verapamil) are used to treat hypertension, but they are not recommended as routine treatment for patients with HFrEF.8 Amlodipine and felodipine neither improve nor worsen the survival of patients with HF72,73; therefore, a dihydropyridine group of calcium channel blockers could be used to control hypertension only after other medications have failed. There are few data assessing the efficacy and safety of other medications or of specific combinations of ≥3 drugs for hypertension in the HF population.74 Accordingly, the recommendation of specific multidrug combinations is largely empirical or anecdotal. Intuitively, it seems most appropriate to continue to combine agents of different mechanisms of action. In that regard, a triple-drug regimen of an ACE inhibitor or ARB, a calcium channel blocker, and a thiazide diuretic is effective and can be well tolerated.74 It should be kept in mind that carvedilol, 1 of the 3 β-blockers proven to reduce mortality in HF, is more effective in reducing BP than metoprolol succinate or bisoprolol because of its combined α1 β1 β2-blocking properties and may be the β-blocker of choice among β-blockers in patients with HFrEF with refractory hypertension. Evidence with other β-blockers with vasodilatory properties such as nebivolol75 and labetolol76 is very limited, and they are not the β-blocker of choice for the treatment of HFrEF according to HF guidelines.8 Experience with older-generation antihypertensive medications such as prazosin, an α-receptor blocker,77 or clonidine, a centrally acting agent,78,79 is again very limited and precedes the evidence with standard HF therapies. Furthermore, studies suggest potential adverse outcomes with these classes of agents that are elaborated below in the Drugs to Avoid in Patients With HF section.In addition to medication choices, the evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance, accurate assessment of treatment adherence and use of good BP measurement techniques to exclude pseudo-resistance, and identification of causes contributing to treatment resistance, including secondary causes of hypertension. In most cases, treatment resistance is multifactorial in origin, with obesity, excessive dietary sodium intake, obstructive sleep apnea (OSA), and chronic kidney disease being particularly common factors in patients with HF.New antihypertension treatment strategies such as renin inhibition with aliskiren failed to improve clinical outcomes in patients with HF,80 and catheter-based renal artery denervation (SYMPLICITY HTN-3 trial [A Controlled Trial of Renal Denervation for Resistant Hypertension]) failed to show a significant reduction of SBP in patients with resistant hypertension.81 Other strategies such as targeting excessive sympathetic nerve activity by carotid body denervation are awaiting clinical validation in the hypertension and HF populations.Drugs to Avoid in Patients With HFSeveral classes of drugs should be avoided in patients with HFrEF with a history of hypertension. Because of their negative inotropic properties and the increased likelihood of worsening HF symptoms, the nondihydropyridine calcium channel blockers such as diltiazem and verapamil should be avoided.8 The dihydropyridine calcium channel blocker amlodipine appeared to be safe in patients with severe HFrEF in the PRAISE trial (Prospective Randomized Amlodipine Survival Evaluation),82 as was felodipine.73 In the current 2013 HF guidelines, most calcium channel–blocking drugs except amlodipine are not recommended.8 Although clonidine is an effective antihypertensive agent, a similar centrally acting drug, moxonidine, was associated with increased mortality in patients with HF; thus, centrally acting norepinephrine-depleting agents may need to be avoided or used with caution in patients with HFrEF.83 In the ALLHAT trial, the α-blocker doxazosin arm of the trial was discontinued because of a 2-fold increase in the risk of developing HF compared with chlorthalidone treatment.45 Although the ALLHAT study excluded patients with established HF and there are caveats about extrapolating these data to the management of hypertension in patients with established HF, the safety and efficacy of α-blockers in the management of patients with HF with hypertension are currently unclear. Potent direct-acting vasodilators such as minoxidil should also be avoided because of their renin-related salt and fluid-retaining effects. Nonsteroidal anti-inflammatory agents should be used with caution in these patients, given their effects on BP, volume status, and renal function.Treatment of Hypertension in Patients With HF With Preserved LVEFMost patients with HF and preserved LVEF (HFpEF), especially elderly women, have hypertension. A significant proportion of these patients also have evidence of LV hypertrophy, and some may have atrial dilatation, cardiac enlargement, and wall motion abnormalities without LV systolic dysfunction. Patients with HFpEF may respond particularly well to the treatment of hypertension with regression of hypertrophy84 and improvement in filling pressures.84,85 Most patients with HFpEF require treatment with cardiac medications for the comorbidities of hypertension, diabetes mellitus, coronary artery disease, and atrial fibrillation. The 2013 HF guidelines suggest that the use of β-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control BP in patients with HFpEF.8 The use of ARBs might also be considered to decrease hospitalizations for patients with HFpEF.8Recommendations Harmonized With Existing Guidelines for the Recognition and Treatment of Patients With HF With HypertensionSee Tables 2 through 4 for a summary of these recommendations.Stage A HFFor patients with hypertension who are at high risk for developing HF in the future but with no functional or structural cardiac disorder at present time, the following is recommended:Hypertension should be controlled in accordance with contemporary guidelines to lower the risk of developing HF (Class I; Level of Evidence A).7–9,21–28,30,31Stage B HFFor patients with hypertension, with cardiac structural abnormalities or remodeling who have not developed HF symptoms, the following is recommended:In patients with structural cardiac abnormalities, including LV hypertrophy, BP should be controlled in accordance with clinical practice guidelines for hypertension t