For a 92-year-old patient with dementia, chronic kidney disease (CKD) and congestive heart failure (CHF) presenting with new onset dizziness and hypotension, should ramipril (Angiotensin-Converting Enzyme inhibitor) or furosemide (loop diuretic) be discontinued first?

Management of New Dizziness and Hypotension in a 92-Year-Old with Dementia, CKD, and CHF

In a 92-year-old patient with dementia, CKD, and CHF who develops new dizziness and hypotension, furosemide should be discontinued first rather than ramipril.

Rationale for Discontinuing Furosemide First

Pathophysiology of Hypotension in this Patient

The patient's presentation with dizziness and hypotension suggests symptomatic hypotension, which requires immediate intervention. Both medications can contribute to hypotension, but through different mechanisms:

1. Furosemide (Loop Diuretic):

   • Causes volume depletion through increased diuresis
   • Can lead to rapid drops in blood pressure, especially in elderly patients
   • Effects can be quickly reversed by discontinuation

2. Ramipril (ACE Inhibitor):

   • Causes vasodilation through inhibition of angiotensin II
   • Provides mortality benefit in heart failure patients
   • Has long-term protective effects for both cardiac and renal function

Guidelines-Based Approach

According to the European Society of Cardiology guidelines, when symptomatic hypotension occurs in a heart failure patient on ACE inhibitors:

• "If no signs or symptoms of congestion, consider reducing diuretic dose" 1
• "If these measures do not solve problem, seek specialist advice" 1

The ESC guidelines specifically state: "Remember: some ACE inhibitor (or ARB) is better than no ACE inhibitor" 1, highlighting the importance of maintaining ACE inhibitor therapy when possible.

Decision Algorithm

1. First step: Discontinue furosemide

   • Rapidly reduces volume depletion
   • Can quickly improve symptomatic hypotension
   • Effects are reversible within 24-48 hours

2. Monitor response:

   • If symptoms improve → maintain ACE inhibitor at current dose
   • If symptoms persist → consider reducing ramipril dose by 50%
   • If severe symptoms continue despite these measures → temporarily discontinue ramipril

3. Reassess in 48-72 hours:

   • Check blood pressure, symptoms, and renal function
   • If stable, consider cautious reintroduction of low-dose diuretic if signs of fluid retention develop

Special Considerations in This Patient

Age and Dementia

• Elderly patients (especially >90 years) are more sensitive to hypotensive effects of medications
• Dementia increases risk of falls with orthostatic hypotension
• Dizziness may be poorly reported or described by patients with cognitive impairment

Chronic Kidney Disease

• CKD patients may have altered drug metabolism and clearance
• Ramipril dosing should be adjusted based on renal function
• However, ACE inhibitors provide renoprotective effects that are beneficial in CKD 2

Congestive Heart Failure

• ACE inhibitors reduce mortality in heart failure patients
• The AIRE study demonstrated that ramipril significantly decreased mortality risk by 27% in heart failure patients 3
• Discontinuing ACE inhibitors can lead to clinical deterioration in heart failure patients 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of both medications simultaneously

   • Can lead to rapid fluid retention and heart failure exacerbation

2. Focusing only on blood pressure numbers

   • Asymptomatic low blood pressure may not require medication changes
   • The ESC guidelines note: "Asymptomatic low blood pressure does not usually require any change in therapy" 1

3. Failing to monitor renal function

   • Both medications affect kidney function
   • Check renal function 1-2 weeks after medication changes

4. Neglecting to consider other causes of dizziness

   • Polypharmacy in elderly patients
   • Orthostatic hypotension from autonomic dysfunction
   • Cerebrovascular disease

Remember that the goal is to maintain the mortality benefit of ACE inhibitors while addressing the immediate symptomatic concern. Diuretics can always be cautiously reintroduced once blood pressure stabilizes, whereas the protective effects of ACE inhibitors are critical to maintain whenever possible.