What are the medication options for a patient with severe hypertension, currently on amlodipine (calcium channel blocker) 7.5 mg daily, lisinopril (angiotensin-converting enzyme inhibitor) 40 mg daily, and metoprolol (beta blocker) 50 mg twice a day (BID), with bradycardia?

From the Guidelines

For a patient with elevated systolic blood pressure of 170 despite being on amlodipine 7.5 mg daily, lisinopril 40 mg daily, and metoprolol 50 mg BID, I recommend adding a thiazide diuretic such as chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 12.5-25 mg daily. Given that the patient is already on maximum doses of lisinopril and a significant dose of amlodipine, with a heart rate in the low 60s, increasing the beta-blocker dose would not be advisable, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The low heart rate suggests caution with further beta-blockade. Adding a thiazide diuretic would provide a complementary mechanism of action by reducing sodium and water retention, which often works synergistically with ACE inhibitors and calcium channel blockers, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1 and the 2024 ESC guidelines 1.

Some key points to consider when adding a thiazide diuretic include:

• Monitoring electrolytes, especially potassium and sodium, after starting the medication
• Assessing renal function within 1-2 weeks of initiating the new medication, especially if the patient has any underlying kidney disease
• Considering alternative options, such as spironolactone 25 mg daily, if the patient has any contraindications to thiazides, as spironolactone is particularly effective in resistant hypertension 1
• Preferably using a fixed-dose single-pill combination treatment to improve adherence, as recommended by the 2024 ESC guidelines 1

It is essential to note that the patient's current medication regimen is not adequately controlling their blood pressure, and adding a thiazide diuretic is a reasonable next step, based on the recommendations from the 2020 international society of hypertension global hypertension practice guidelines 1 and the 2024 ESC guidelines 1.

From the FDA Drug Label

WARNINGS ... If angina markedly worsens or acute coronary insufficiency develops, metoprolol administration should be reinstated promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken. ... Bradycardia Bradycardia, including sinus pause, heart block, and cardiac arrest have occurred with the use of metoprolol. Patients with first-degree atrioventricular block, sinus node dysfunction, or conduction disorders may be at increased risk. Monitor heart rate and rhythm in patients receiving metoprolol. If severe bradycardia develops, reduce or stop metoprolol

The patient is already on metoprolol 50 mg BID with a heart rate in the low 60s, which may indicate bradycardia.

• The current medication regimen includes amlodipine 7.5 mg daily and lisinopril 40 mg daily.
• Considering the patient's elevated blood pressure and current medication regimen, adjusting the dose of metoprolol or adding another antihypertensive medication could be options.
• However, given the patient's low heart rate, reducing the dose of metoprolol or switching to a different beta-blocker may be necessary to avoid worsening bradycardia 2.

From the Research

Medication Options for Elevated Blood Pressure

The patient is currently taking amlodipine 7.5 mg daily, lisinopril 40 mg daily, and metoprolol 50 mg BID, with a systolic blood pressure of 170 mmHg and a heart rate in the low 60s.

• The combination of lisinopril and amlodipine has been shown to be effective in treating hypertension, particularly in patients with comorbidities such as arteriosclerosis obliterans 3.
• However, the current doses of amlodipine and lisinopril may not be sufficient to achieve the target blood pressure, and increasing the doses or adding other medications may be necessary 4.
• The patient's heart rate is already in the low 60s, which may limit the use of beta blockers such as metoprolol, and alternative medications such as calcium channel blockers or ACE inhibitors may be considered 5.
• In patients with severely elevated blood pressure, such as this patient, immediate blood pressure lowering medication is often necessary, and calcium antagonists are commonly used 6.
• The management of severely elevated blood pressure in primary care settings has been shown to be challenging, and patients often do not receive the recommended evaluation, medical regimen modification, and discharge instructions 7, 6.

Potential Treatment Strategies

• Increasing the dose of amlodipine or lisinopril, or adding other medications such as a diuretic or a beta blocker, may be necessary to achieve the target blood pressure 4.
• Alternative medications such as an angiotensin receptor blocker (ARB) or a direct renin inhibitor may be considered if the patient is not responding to the current medication regimen 5.
• Close monitoring of the patient's blood pressure and heart rate is necessary to adjust the medication regimen as needed and to prevent potential complications such as hypotension or bradycardia 6.