Combination therapy with ARBs and Beta-blockers for post-PCI patients with hypertension-Expert Opinion of Indian Cardiologists

Out of 593 cardiologists, 57.5% opined that heart failure (HF) was more common in patients with hypertension indicated for PCI, while it was diabetes as per 50.3% of the panel experts.

The target BP after PCI for patients aged <65 years and >65 years was recommended to be 121–130/80 mmHg by 39% of experts while 131–140/90 mmHg by 33.2% of experts, respectively, with a target heart rate of 60–80 bpm.

Angiotensin II receptor blockers were the first choice of antihypertensive therapy irrespective of co-morbid conditions (arrhythmia, diabetes, dyslipidemia, heart failure, and stroke) and Beta-blockers were the second preferred antihypertensive agents post-procedure in hypertensive patients with comorbid conditions.

A combination of ARBs and beta-blockers after the intervention was suggested in hypertensive patients with coronary artery disease and diabetes mellitus (57.0%), stroke (41.1%), and HF (44.9%).

Among beta-blockers, metoprolol was the most preferred drug post-procedure for 77% of the survey participants and 46% preferred metoprolol in HF.

There has been progress in managing hypertension, but a considerable proportion of Indians still have uncontrolled blood pressure (BP), especially after PCI (percutaneous coronary intervention). The experts recommend titrating antihypertensive doses, once the intervention is done, progressively raising them to the pre-intervention levels in accordance with patient response and tolerance.

Experts also highlighted that following up within 15 days after the procedure was standard protocol for patients with numerous comorbidities, including uncontrolled hypertension. Patients at high risk need to be closely monitored.

The key recommendations from a panel of experts are as follows:

• Hypertensive patients indicated for PCI are more commonly associated with HF and diabetes and should be screened routinely.
• The target BP of 121-130/80 mmHg and 131-140/90 mmHg are recommended in patients <65 years and >65 years after PCI, respectively, and not <120 mmHg SBP.
• In hypertensive patients, post PCI, the target heart rate should be 60-80 bpm.
• In patients with hypertension and different comorbidities (arrhythmia, diabetes, dyslipidemia, HF and stroke), ARBs should be considered as first-line therapy after PCI.
• In hypertensive patients with CAD and multiple comorbidities, a combination of ARBs and Beta-blockers is the preferred combination therapy over the other antihypertensive therapies.
• The use of Beta-blockers over ARBs in patients with arrhythmia should be considered. However, ARBs can be considered alongside beta-blockers due to their antihypertensive efficacy.
• Among Beta-blockers, metoprolol is the first treatment choice for post-PCI and HF patients.
• Uncontrolled hypertensive patients, post-PCI, should be asked to follow-up within 15 days post-procedure or earlier.

Reference: Kumar, Arram Sreenivas; Kumar, Viveka1; Shah, Chetan P.2; Kasturi, Sridhar3; Birla, Ashish4; Revankar, Santosh4; Yadav, Neeraj Kumar4. Hypertension Management in Pre- and Post-Percutaneous Coronary Intervention Patients: An Expert Opinion of Cardiologists from India. Journal of the Practice of Cardiovascular Sciences 10(1):p 18-24, Jan–Apr 2024. | DOI: 10.4103/jpcs.jpcs_59_23