How to manage a 68-year-old male patient with hypertension (HTN) on Lisinopril (Zestril) 40 mg, Metoprolol (Lopressor) 50 mg, and Amlodipine (Norvasc) 10 mg, who experiences daily lightheadedness, particularly with positional changes, and is undergoing orthostatic blood pressure measurement?

From the Guidelines

For this 68-year-old male with hypertension experiencing daily lightheadedness with positional changes, I recommend reducing his antihypertensive medication burden to address likely orthostatic hypotension. First, decrease Amlodipine from 10mg to 5mg daily while maintaining Lisinopril 40mg and reducing Metoprolol to 25mg twice daily. Monitor blood pressure both sitting and standing, targeting a systolic pressure no lower than 130-140 mmHg while seated, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Advise the patient to rise slowly from sitting or lying positions, stay well-hydrated, and avoid prolonged standing. Consider adding compression stockings to improve venous return. If symptoms persist after medication adjustment, further dose reductions may be necessary, potentially discontinuing Amlodipine completely. The patient's symptoms suggest orthostatic hypotension from excessive blood pressure lowering, as his triple therapy at high doses is causing an exaggerated drop in blood pressure upon position changes, which is consistent with the findings of the 2024 ESC guidelines 1 and other studies 1. Regular follow-up within 1-2 weeks after medication changes is essential to ensure symptom improvement while maintaining adequate blood pressure control. Additionally, non-pharmacological measures such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen may be beneficial, as recommended by the standards of medical care in diabetes-2022 1 and other studies 1. It is also important to note that the diagnosis of orthostatic hypotension should be made based on a drop of ≥20/10 mmHg in blood pressure 1 and/or 3 min after standing, as defined by the 2024 ESC guidelines 1.

From the Research

Patient Management

To manage the 68-year-old male patient with hypertension (HTN) on Lisinopril 40 mg, Metoprolol 50 mg, and Amlodipine 10 mg, who experiences daily lightheadedness, particularly with positional changes, the following steps can be taken:

• Evaluate the patient for orthostatic hypotension (OH) by measuring orthostatic blood pressure, as the patient's symptoms suggest a possible diagnosis of OH 2, 3.
• Review the patient's medication list to identify potential causes of OH, such as antihypertensives, and consider adjusting or discontinuing medications that may be contributing to the condition 4, 5.
• Consider non-pharmacological interventions, such as:
  • Increasing fluid and sodium intake
  • Wearing compression stockings
  • Elevating the head of the bed
  • Encouraging slow position changes
  • Using abdominal binders to prevent postprandial hypotension 3, 5.
• If non-pharmacological interventions are insufficient, consider pharmacological therapies, such as:
  • Fludrocortisone
  • Midodrine
  • Pyridostigmine
  • Atomoxetine
  • Droxidopa 2, 3, 6, 5.

Diagnostic Considerations

• Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position 2, 3.
• The patient's symptoms, such as lightheadedness and dizziness, are consistent with a diagnosis of OH 2, 3.
• Head-up tilt-table testing can aid in confirming a diagnosis of suspected OH when standard orthostatic vital signs are nondiagnostic 2.

Treatment Goals

• Improve hypotension without excessive supine hypertension
• Relieve orthostatic symptoms
• Improve standing time 2, 6.
• Manage both OH and hypertension, as uncontrolled hypertension can worsen OH 5.