Management of hypertension associated with cardiovascular failure

Hypertension (HT) treatment should focus on the prevention of new-onset heart failure (HF) or its exacerbation due to the increasing trend of HF incidence in Japan. According to the SPRINT trial, strict control of blood pressure (BP) of approximately 120 mmHg suppresses the progression of HF stages A and B to a more severe stage. However, in stages C and D, the target value for BP reduction differs depending on whether HF is HF reduced ejection fraction (EF) (HFrEF) or HF preserved EF (HFpEF). Additionally, the relationship between BP control and the prognosis of HF mostly showed the J-curve phenomenon in both HFrEF and HFpEF; however, patients with HFpEF need a lower target BP value than those with HFrEF. One reason is that vascular failure is associated with the pathophysiology of HF. Therefore, it is important to utilize an antihypertensive treatment strategy that considers vascular insufficiency. In addition, the presence or absence of compelling indications is important for the selection of antihypertensive (with cardioprotective effects for HF) medications. The uptitration of cardioprotective medications such as angiotensin-converting enzyme inhibitors/angiotensin II type 1a receptor blockers and beta-blockers is recommended in patients with HFrEF; however, it is often not practically possible to increase the dosage. In these cases, the use of medications in combination with other medication classes is also useful. Moreover, it is also useful to properly use medications of the same class considering their onset of action and half-life in the blood. It is still unclear how cardioprotective medications are used in patients with HFrEF, especially on certain age groups. The optimal initiation and continuation of cardioprotective medications should be carefully determined.