What is the management of a 97-year-old female (YOF) with stage 2 hypertension, currently taking perindopril (Angiotensin-Converting Enzyme Inhibitor) 8mg/day and diltiazem (Calcium Channel Blocker) with a heart rate (HR) of 66 beats per minute?

From the Guidelines

I recommend adding a low dose of spironolactone to this 97-year-old female patient's regimen to address her elevated systolic blood pressure of 189 mmHg, as her current medications of perindopril 8mg daily (an ACE inhibitor) and diltiazem (a calcium channel blocker) are not providing adequate blood pressure control. Her current heart rate of 66 beats per minute is appropriate, but her blood pressure needs to be addressed to reduce the risk of cardiovascular complications. When initiating spironolactone, monitor electrolytes (particularly potassium) within 1-2 weeks, as spironolactone can cause hyperkalemia, especially in elderly patients with renal impairment 1. Also, check renal function, as the combination of an ACE inhibitor with spironolactone increases the risk of acute kidney injury. The target blood pressure for this patient should be less conservative than for younger patients, aiming for systolic blood pressure <150 mmHg rather than <130 mmHg, considering her advanced age and the risk of orthostatic hypotension. This three-drug combination (ACE inhibitor, calcium channel blocker, and spironolactone) provides complementary mechanisms of action: ACE inhibitors block the renin-angiotensin system, calcium channel blockers cause vasodilation, and spironolactone acts as a diuretic and blocks aldosterone receptors, which should effectively lower her significantly elevated systolic blood pressure. It is essential to note that the 2020 international society of hypertension global hypertension practice guidelines recommend adding a low dose of spironolactone as the 4th line agent in patients whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets 1. In this case, since the patient's current medications are not providing adequate blood pressure control, adding spironolactone is a reasonable next step, considering her advanced age and the need to balance the benefits and risks of treatment. Some studies suggest that thiazide diuretics may be effective in lowering blood pressure in elderly patients, but the most recent and highest-quality study recommends spironolactone as the 4th line agent 1. Therefore, based on the latest evidence, adding a low dose of spironolactone to the patient's regimen is the most appropriate recommendation.

From the FDA Drug Label

In elderly patients (>70 yrs), perindopril erbumine tablets should be given as a 2 mg dose once daily in the first week, followed by 4 mg once daily in the second week and 8 mg once daily for maintenance dose if tolerated. The daily dosage may be titrated upward until blood pressure, when measured just before the next dose, is controlled, but experience with perindopril erbumine tablets is limited in the elderly at doses exceeding 8 mg. Dosages above 8 mg should be administered with caution and under close medical supervision.

The patient is already taking the maximum recommended dose of 8mg/day for a patient over 70 years old.

• The current blood pressure is 189/79, which is high.
• The patient is already taking perindopril 8mg/day and diltiazem.
• The heart rate is 66, which is within normal limits. Given the patient's age and current dosage, it is recommended to exercise caution and consider alternative treatments or adjustments under close medical supervision 2.

From the Research

Patient's Current Condition

• The patient is a 97-year-old female (YOF) with a systolic blood pressure (SBP) of 189 mmHg and a diastolic blood pressure (DBP) of 79 mmHg.
• The patient is already taking perindopril 8mg/day and diltiazem, with a heart rate (HR) of 66 beats per minute.

Treatment of Hypertension

• According to 3, first-line therapy for hypertension consists of lifestyle modification and medication, with a target SBP/DBP of <130/80 mmHg for adults <65 years and SBP <130 mmHg for adults ≥65 years.
• The study 4 discusses the initiation of antihypertensive drug treatment and the target levels for systolic blood pressure, recommending that treatment be initiated when SBP is at least 140 mmHg or DBP is at least 90 mmHg in patients with grade 1 hypertension and low or moderate total cardiovascular risk.

Effectiveness of Perindopril

• The study 5 evaluates the efficacy and tolerability of perindopril added to hydrochlorothiazide therapy in patients with mild to moderate essential hypertension, finding that the combination of perindopril and hydrochlorothiazide is safe and effective in lowering blood pressure.
• The results of this study indicate that lower doses of perindopril are as effective as higher doses when combined with hydrochlorothiazide.

Antihypertensive Drugs

• The review 6 describes the various pharmacological classes of antihypertensive drugs, including their mechanisms of action and side effects, and discusses the importance of choosing the right medication for each patient.
• The study 7 examines the separate relations of systolic, diastolic, and pulse pressure with risk for congestive heart failure, finding that systolic and pulse pressure are stronger predictors of risk for heart failure than diastolic pressure.

Considerations for the Patient's Treatment

• Given the patient's age and current blood pressure, it is essential to consider the potential risks and benefits of adjusting their medication regimen, as discussed in 3 and 4.
• The patient's current medication, perindopril, has been shown to be effective in lowering blood pressure, as demonstrated in 5.
• The choice of antihypertensive medication should be based on the patient's individual needs and medical history, taking into account the different pharmacological classes of antihypertensive drugs and their potential side effects, as discussed in 6.