What is the most effective antihypertensive medication for elderly patients with Coronary Artery Disease (CAD)?

From the Guidelines

Beta-blockers and calcium channel blockers are the preferred antihypertensives for elderly patients with coronary artery disease (CAD), with a target blood pressure of around 130-139/70-79 mmHg. For most elderly CAD patients, a beta-blocker such as metoprolol (starting at 25-50 mg twice daily) or bisoprolol (2.5-5 mg once daily) would be first-line therapy, as they reduce myocardial oxygen demand by decreasing heart rate and contractility, which helps prevent angina and reduces cardiovascular events 1. If beta-blockers are contraindicated or poorly tolerated, long-acting dihydropyridine calcium channel blockers like amlodipine (5-10 mg daily) are excellent alternatives.

Some key points to consider when treating elderly patients with CAD include:

• Starting with low doses and titrating gradually while monitoring for orthostatic hypotension, electrolyte disturbances, and renal function changes 1
• Considering ACE inhibitors or ARBs as part of the regimen, particularly in patients with left ventricular dysfunction, diabetes, or chronic kidney disease 1
• Avoiding excessive lowering of diastolic blood pressure to prevent deleterious reductions in coronary blood flow 1
• Using non-pharmacologic approaches to management of hypertension, such as lifestyle modifications, as initial therapy or to reduce the need for pharmacologic therapy 1

It's also important to note that the benefits of antihypertensive therapy are particularly high in patients 60 to 80 years of age, and that treatment prevents strokes and heart failure more than coronary events, but overall mortality is also reduced 1. Additionally, the incidence of cardiovascular events decreases steeply in relation to the achieved blood pressure value, and is markedly less in patients with blood pressure control versus those without control 1.

From the FDA Drug Label

In a clinical study of lisinopril in patients with myocardial infarctions (GISSI-3 Trial) 4,413 (47%) were 65 and over, while 1,656 (18%) were 75 and over. In this study, 4.8 % of patients aged 75 years and older discontinued lisinopril treatment because of renal dysfunction vs. 1. 3% of patients younger than 75 years. No other differences in safety or effectiveness were observed between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Clinical studies of amlodipine did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy Elderly patients have decreased clearance of amlodipine with a resulting increase of AUC of approximately 40 to 60%, and a lower initial dose may be required [see Dosage and Administration (2.1)] .

The best antihypertensive for elderly with coronary artery disease is lisinopril.

• Lisinopril has been shown to be effective and safe in elderly patients, with no significant differences in safety or effectiveness compared to younger patients 2.
• Amlodipine may also be considered, but the clinical studies did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects 3.
• It is essential to consider the patient's overall health, including renal function, and to start with a low dose and adjust as needed.
• Lisinopril is preferred due to its established safety and efficacy in elderly patients with coronary artery disease.

From the Research

Antihypertensive Treatment for Elderly with Coronary Artery Disease

• The treatment of hypertension in patients with coronary artery disease (CAD) is crucial, and guidelines recommend the use of beta blockers and ACE inhibitors or angiotensin receptor blockers (ARBs) 4.
• Long-acting nitrates are effective antianginal and anti-ischemic drugs, and calcium-channel blockers (CCBs) may be added if angina persists despite beta blockers and long-acting nitrates 4.
• The blood pressure target for patients aged ≤ 80 years is < 140/90 mm Hg, and for those ≥ 80 years, the systolic blood pressure should be < 150 mm Hg 4.

Medication Use in Elderly Patients with CAD

• A study found that in older patients with CAD, the prevalence of use of antiplatelet drugs, beta-blockers, statins, and ACE inhibitors or ARBs was high, with 98% using aspirin or clopidogrel, 96% using beta-blockers, 87% using statins, and 85% using ACE inhibitors or ARBs 5.
• Another study found that calcium channel blockers were used more often than beta blockers in patients with previous myocardial infarction or CAD, and were the most frequently used antihypertensive drugs in older patients with hypertension 6.

Considerations for Elderly Patients with CAD

• Elderly patients with CAD are at increased risk for ischemic recurrences and bleeding complications, and treatment regimens should aim to reduce bleeding while preserving efficacy 7.
• Frailty burden, comorbidities, and body composition abnormalities should be taken into account when making treatment decisions for elderly patients with CAD 8.
• Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD, but frail older adults are still underrepresented in the literature 8.