How to manage significantly elevated blood pressure in an 86-year-old female with HFpEF on terazosin, nitroglycerin, and irbesartan?

Management of Severe Hypertension in an Elderly Patient with HFpEF

The patient's severely elevated blood pressure (213/80 mmHg) requires immediate intensification of antihypertensive therapy with the addition of a calcium channel blocker and optimization of her current regimen.

Current Situation Assessment

This 86-year-old female presents with:

• Severely elevated BP: 213/80 mmHg
• Heart failure with preserved ejection fraction (HFpEF)
• Current medications:
  • Terazosin 2mg at bedtime (alpha-1 blocker)
  • Nitroglycerin 0.2 patch (nitrate)
  • Irbesartan 150mg (ARB)

Treatment Strategy

Immediate Management

1. Intensify antihypertensive therapy:

   • Add a long-acting dihydropyridine calcium channel blocker (CCB) such as amlodipine 5mg daily 1
   • Increase irbesartan to 300mg daily (maximum dose) 1
   • Continue terazosin 2mg at bedtime

2. Consider SGLT2 inhibitor addition:

   • Add an SGLT2 inhibitor (e.g., empagliflozin 10mg daily) which is specifically recommended for HFpEF patients with hypertension 1

3. Optimize diuretic therapy:

   • Add a thiazide-like diuretic (e.g., chlorthalidone 12.5mg daily) to address volume status 1

Blood Pressure Target

For this 86-year-old patient with HFpEF:

• Target systolic BP: 130-139 mmHg 1
• Avoid lowering diastolic BP below 70 mmHg to prevent myocardial ischemia 1

Rationale for Recommendations

1. Medication selection:

   • The 2024 ESC guidelines recommend that patients with HFpEF benefit from SGLT2 inhibitors for improving outcomes while also providing modest BP reduction 1
   • Calcium channel blockers are effective and safe in HFpEF patients, unlike in HFrEF where non-dihydropyridine CCBs should be avoided 1
   • The combination of an ARB (irbesartan), CCB, and diuretic provides multi-mechanism BP control 2

2. Terazosin considerations:

   • While terazosin is effective for hypertension, it's not a first-line agent for HFpEF 3, 4
   • However, in resistant hypertension, alpha-blockers like terazosin can be useful as add-on therapy 1
   • Continue terazosin as it's already part of the regimen and the patient is likely tolerating it well 5, 6

3. Target BP rationale:

   • The 2024 ESC guidelines recommend a systolic BP target of 130-139 mmHg for elderly patients (≥65 years) with heart failure 1
   • More aggressive BP lowering could increase risk of falls and orthostatic hypotension in this 86-year-old patient

Monitoring and Follow-up

1. Short-term follow-up:

   • Schedule follow-up within 1-2 weeks to assess response to therapy
   • Monitor for orthostatic hypotension (measure BP lying and standing)
   • Check electrolytes and renal function within 2-4 weeks after medication changes

2. Home BP monitoring:

   • Recommend home BP monitoring with a validated device
   • Target consistent readings <140/90 mmHg
   • Instruct patient to keep a BP log

Potential Pitfalls and Cautions

1. First-dose hypotension:

   • Advise taking first dose of any new medication at bedtime to minimize risk of syncope 3
   • Caution about orthostatic hypotension, especially with combination of terazosin and other antihypertensives

2. Medication interactions:

   • Monitor for excessive hypotension with the combination of nitrates and other antihypertensives
   • Avoid NSAIDs which can worsen both hypertension and heart failure

3. Age-related considerations:

   • Avoid overly aggressive BP lowering in this elderly patient
   • Start new medications at lower doses and titrate gradually
   • Monitor renal function closely, especially with combination therapy

4. Resistant hypertension approach:

   • If BP remains uncontrolled despite optimized triple therapy, consider adding spironolactone 25mg daily if renal function permits 1

By following this approach, the patient's severely elevated blood pressure can be managed effectively while addressing her underlying HFpEF condition.