What is the next step in managing a 93-year-old female patient with hypertension who is currently taking amlodipine 10mg daily and metoprolol 25mg PO bid?

Management of Hypertension in a 93-Year-Old Female

For a 93-year-old female with blood pressure of 157/79 mmHg on amlodipine 10mg daily and metoprolol 25mg twice daily, the next step should be adding a thiazide diuretic while considering a more lenient blood pressure target of <140/90 mmHg appropriate for her advanced age.

Assessment of Current Status

• Current BP: 157/79 mmHg
• Current medications:
  • Amlodipine 10mg daily (maximum recommended dose) 1
  • Metoprolol 25mg twice daily

Treatment Considerations for Very Elderly Patients

Age-Appropriate BP Targets

• For patients ≥85 years old, the European Society of Cardiology recommends a more lenient target of <140/90 mmHg 2
• A reasonable BP target for elderly patients is 140-150/90 mmHg with careful monitoring for orthostatic hypotension and adverse effects 2

Medication Selection

1. Current regimen analysis:

   • Patient is already on maximum dose of amlodipine (10mg) 1
   • Metoprolol dose is relatively low and could potentially be optimized
   • The patient has uncontrolled systolic hypertension despite two antihypertensive agents

2. Next step options:

   • Add a thiazide diuretic as a third agent (preferred option)

     • This follows the standard approach for resistant hypertension 2
     • Creates a complementary three-drug regimen targeting different mechanisms

   • Consider adding an ARB/ACE inhibitor

     • While guidelines recommend RAS blockers when BP remains uncontrolled on a three-drug regimen 2, in this case, adding a diuretic first would be more appropriate

Implementation Plan

1. Add a thiazide diuretic (e.g., hydrochlorothiazide 12.5mg daily)

   • Start at a low dose to minimize adverse effects in this very elderly patient
   • Monitor for electrolyte disturbances, particularly potassium and sodium

2. Monitoring recommendations:

   • Follow up in 2-4 weeks to assess medication tolerance and BP response 2
   • Check electrolytes and renal function within 1-2 weeks of starting the diuretic
   • Assess for orthostatic hypotension at follow-up visits
   • Monitor for signs of adverse effects from current medications

Important Considerations and Cautions

• Frailty assessment: Evaluate for frailty, as frail elderly patients may benefit from less aggressive BP targets 2, 3

• Orthostatic hypotension: Measure BP both sitting and standing to detect orthostatic changes that could increase fall risk 2

• Medication burden: Consider the total medication burden and potential for drug interactions

• Deprescribing potential: If BP becomes too low with the addition of a third agent, consider reducing the metoprolol dose rather than discontinuing the new medication 4

• Avoid lowering diastolic BP below 60 mmHg as this can increase cardiovascular risk in older adults 3

Alternative Approaches

If the patient cannot tolerate a thiazide diuretic or has contraindications:

• Consider optimizing the metoprolol dose before adding a third agent
• Consider spironolactone as an alternative fourth-line agent, though with careful monitoring for hyperkalemia 2

If BP remains uncontrolled despite optimized triple therapy, referral to a hypertension specialist is recommended 2.