What advice to give to an 82-year-old male hypertensive patient with improved blood pressure on atenolol (beta blocker) 25 mg and Olmesartan (angiotensin II receptor antagonist) 5 mg?

From the Guidelines

For an 82-year-old male hypertensive patient with improved blood pressure on atenolol 25 mg and olmesartan 5 mg, I recommend continuing the current medication regimen while implementing regular blood pressure monitoring at home, as this approach is supported by the most recent guidelines 1. The patient should measure his blood pressure twice daily (morning and evening) and keep a log to share at follow-up appointments.

Key Considerations

• It's essential to maintain a low-sodium diet (less than 2,300 mg daily) and engage in appropriate physical activity like walking 20-30 minutes daily as tolerated.
• Limiting alcohol consumption and avoiding NSAIDs, which can interfere with blood pressure control, is also crucial.
• The patient should be aware of potential side effects of atenolol, such as fatigue or dizziness, and olmesartan's possible effects, including dizziness when standing.
• Regular follow-up appointments every 3-6 months are necessary to monitor kidney function, electrolytes, and assess medication effectiveness, as recommended by recent guidelines 1.

Rationale

The combination therapy of atenolol and olmesartan is beneficial for this patient, as atenolol reduces heart rate and cardiac output, while olmesartan blocks angiotensin II receptors, relaxing blood vessels through different mechanisms for effective blood pressure control in elderly patients. The 2024 ESC guidelines for the management of elevated blood pressure and hypertension support the continuation of BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated 1. Additionally, the guidelines recommend testing for orthostatic hypotension before starting or intensifying BP-lowering medication, which is an important consideration for this patient.

Monitoring and Follow-up

Given the patient's age and medication regimen, it's crucial to monitor for potential side effects and adjust the treatment plan as needed. The patient's blood pressure should be maintained within the recommended range, with a systolic blood pressure target of 130-139 mmHg, as suggested by the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. By following these recommendations and continuing the current medication regimen, the patient's blood pressure can be effectively managed, reducing the risk of micro- and macrovascular complications.

From the FDA Drug Label

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Some renally-impaired or elderly patients being treated for hypertension may require a lower starting dose of atenolol: 25 mg given as one tablet a day. If this 25 mg dose is used, assessment of efficacy must be made carefully This should include measurement of blood pressure just prior to the next dose (“trough” blood pressure) to ensure that the treatment effect is present for a full 24 hours.

The patient is already on a low dose of atenolol (25 mg), which is appropriate for an elderly patient. To advise this patient further, it is essential to:

• Continue monitoring blood pressure to ensure the treatment effect is present for a full 24 hours
• Assess renal function regularly, as atenolol is excreted by the kidneys
• Be cautious when adjusting the dose, considering the patient's age and potential renal impairment 2
• Schedule follow-up appointments to evaluate the patient's response to the current treatment regimen and make any necessary adjustments.

From the Research

Patient Advice and Follow-up

The patient, an 82-year-old male with hypertension, has shown improvement in blood pressure after being started on atenolol 25 mg and olmesartan 5 mg. To advise this patient further, consider the following points:

• Medication Adherence: Emphasize the importance of continuing the prescribed medication regimen as directed, given that both atenolol 3 and olmesartan 4, 5 have been shown to be effective in managing hypertension.
• Monitoring Blood Pressure: Regular monitoring of blood pressure is crucial to assess the effectiveness of the treatment and make any necessary adjustments. The patient's current blood pressure of 150/60 mmHg and heart rate of 70 bpm should be compared with future readings to evaluate the ongoing efficacy of the medication.
• Lifestyle Modifications: In addition to medication, advise the patient on lifestyle changes that can help manage hypertension, such as a balanced diet, regular physical activity, stress reduction, and limiting alcohol intake.
• Follow-up Appointments: Schedule regular follow-up appointments to monitor the patient's blood pressure, adjust the medication as needed, and address any concerns or side effects the patient may be experiencing.
• Potential Side Effects: Inform the patient about potential side effects of atenolol and olmesartan, such as dizziness, fatigue, or cough, and instruct them to report any unusual symptoms promptly.

Considerations for Atenolol and Olmesartan

When managing the patient's hypertension with atenolol and olmesartan, consider the following:

• Atenolol: This beta-blocker has been shown to effectively reduce blood pressure in hypertensive patients 3 and can be particularly useful in patients with certain cardiovascular conditions. However, its use may require careful monitoring, especially in patients with diabetes or those prone to hypotension.
• Olmesartan: As an angiotensin II receptor antagonist, olmesartan not only lowers blood pressure but may also offer protective effects against cardiovascular morbidity and mortality 4, 5. Its unique mechanism of action, which includes potential inhibitory effects on angiotensin-converting enzyme 6, makes it a valuable option for hypertension management.

Future Management

For future management, consider the following steps:

• Regular Blood Pressure Checks: Continue to monitor the patient's blood pressure regularly to ensure that the current medication regimen is effective.
• Adjust Medication as Needed: Be prepared to adjust the dosage or type of medication based on the patient's response to treatment and any side effects that may arise.
• Encourage Healthy Lifestyle Habits: Reinforce the importance of a healthy diet, regular exercise, and other lifestyle modifications that can help control hypertension and improve overall health.