Which class of drug should be used to treat a patient who has maximized all of his heart failure medications (amlodipine [Norvasc], ACE inhibitor, beta blocker) yet still has elevated BP?
—Deborah Skinner, NP, Muskegon, Mich.

Consider adding an angiotensin receptor blocker to the regimen. The combination of nitrate and hydralazine, particularly in the African-American population, would be a good choice. If there is post-MI congestive heart failure with a reduction in ejection fraction, an aldosterone antagonist should be prescribed. If the patient is already taking all classes of medications that have a beneficial antihypertensive effect, a diuretic can also be added.
—Norma M. Keller, MD (101-16)