What is the next step to manage a 68-year-old female patient with hypertension (HTN) whose blood pressure remains elevated at 158/110 mmHg despite recently increased lisinopril (angiotensin-converting enzyme inhibitor) to 40 mg?

From the Guidelines

The next step for this 68-year-old female with uncontrolled hypertension is to add a thiazide diuretic such as chlorthalidone 12.5-25 mg daily to her regimen, as recommended by the 2020 International Society of Hypertension global hypertension practice guidelines 1. Since her blood pressure remains significantly elevated at 158/110 mmHg despite maximum dosing of lisinopril (40 mg), combination therapy is now indicated. Thiazide diuretics work synergistically with ACE inhibitors by addressing different pathophysiological mechanisms of hypertension - while lisinopril blocks the renin-angiotensin-aldosterone system, thiazides reduce blood volume and vascular resistance. This patient's diastolic pressure of 110 mmHg is particularly concerning and requires prompt intervention. Some key points to consider in managing this patient's hypertension include:

• Ensuring accurate office blood pressure measurements and assessing for nonadherence to prescribed antihypertensive medications, as outlined in the 2018 American College of Cardiology/American Heart Association hypertension guideline 1
• Identifying and addressing contributing lifestyle factors, such as weight loss, dietary changes, and increased physical activity, as recommended by the 2018 Diabetes Care standards of medical care in diabetes 1
• Considering the addition of other agents, such as a calcium channel blocker, if the target blood pressure is not achieved with the current regimen, as suggested by the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense clinical practice guideline 1
• Monitoring for potential side effects, such as electrolyte abnormalities and renal function changes, as noted in the 2018 Resistant Hypertension scientific statement from the American Heart Association 1. Throughout this medication adjustment, the patient should be closely monitored for any adverse effects, particularly given her age and risk for falls.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily.

The patient is already on the maximum dose of lisinopril (40 mg) and still has elevated blood pressure. The next step would be to consider adding another antihypertensive agent to the patient's regimen, such as a diuretic (e.g., hydrochlorothiazide) or a beta blocker (e.g., atenolol or metoprolol), as these combinations have been shown to be effective in reducing blood pressure in clinical studies 2.

• Key considerations:
  • The patient's blood pressure is not adequately controlled on lisinopril alone.
  • The addition of another antihypertensive agent may help to achieve better blood pressure control.
  • The choice of additional agent will depend on the patient's individual characteristics, such as comorbidities and potential side effects.

From the Research

Next Steps to Manage Hypertension

The patient's blood pressure remains elevated at 158/110 mmHg despite recently increased lisinopril to 40 mg. The next steps to manage this patient's hypertension could include:

• Adding a diuretic to the current regimen, as studies have shown that the combination of an angiotensin-converting enzyme (ACE) inhibitor and a diuretic can be effective in reducing blood pressure 3, 4.
• Considering alternative antihypertensive agents, such as calcium channel blockers, as the patient's blood pressure is not adequately controlled with lisinopril alone 5.
• Evaluating the patient's renal function, as lisinopril can be effective in patients with impaired renal function, but may require dose adjustments 6.

Potential Benefits of Adding a Diuretic

Adding a diuretic to the patient's current regimen may provide several benefits, including:

• Enhanced blood pressure reduction, as diuretics can help to reduce fluid volume and alleviate pressure on the blood vessels 3, 4.
• Improved cardiovascular outcomes, as diuretics have been shown to reduce the risk of cardiovascular events in patients with hypertension 5.

Considerations for Alternative Antihypertensive Agents

When considering alternative antihypertensive agents, it is essential to evaluate the patient's individual needs and medical history. For example:

• Calcium channel blockers may be a suitable alternative for patients who are not responding to ACE inhibitors, but may have different side effect profiles 5.
• The patient's renal function and other comorbidities should be taken into account when selecting an alternative antihypertensive agent 6.