What is the concern for a 53-year-old male on lisinopril (angiotensin-converting enzyme inhibitor) and metoprolol (beta blocker) with hypertension (blood pressure 191/112)?

From the Guidelines

For a 53-year-old male on lisinopril and metoprolol with a blood pressure of 191/112, immediate intervention is needed as this represents severe hypertension. I recommend increasing the current medication doses and adding a third antihypertensive agent. Specifically, optimize the lisinopril to 40mg daily and metoprolol to the maximum tolerated dose (up to 200mg daily depending on current dose and heart rate) 1. Add amlodipine 5-10mg daily as a third agent from a different class (calcium channel blocker) 1. The patient should monitor blood pressure twice daily and follow up within 1-2 weeks. If blood pressure remains above 160/100 despite these adjustments, urgent medical evaluation is necessary. This severe hypertension significantly increases risk for stroke, heart attack, and kidney damage. The combination therapy approach targets different blood pressure mechanisms: lisinopril blocks the renin-angiotensin system, metoprolol reduces cardiac output, and amlodipine causes peripheral vasodilation. Additionally, the patient should restrict sodium intake to less than 2g daily, maintain physical activity, limit alcohol consumption, and ensure medication adherence. It is also important to note that the current guidelines suggest that the combination of an ACEI and an ARB is not recommended due to increased risk of end-stage renal disease and stroke 1.

Key Considerations

• The patient's current blood pressure is significantly elevated, posing a high risk for cardiovascular complications.
• The current medication regimen includes an ACEI (lisinopril) and a beta-blocker (metoprolol), which may not be sufficient to control the patient's blood pressure.
• The addition of a calcium channel blocker (amlodipine) can help to further reduce blood pressure and minimize cardiovascular risk.
• Lifestyle modifications, including sodium restriction, physical activity, and limited alcohol consumption, are also essential for managing hypertension.

Monitoring and Follow-up

• The patient should monitor blood pressure twice daily and follow up with their healthcare provider within 1-2 weeks to assess the effectiveness of the revised treatment plan.
• If blood pressure remains elevated despite these adjustments, urgent medical evaluation is necessary to prevent potential complications.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily. Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian Lisinopril was approximately equivalent to atenolol and metoprolol in reducing diastolic blood pressure, and had somewhat greater effects on systolic blood pressure.

The concern for a 53-year-old male on lisinopril and metoprolol with hypertension (blood pressure 191/112) is that his blood pressure is not adequately controlled, as it is significantly higher than the normal range. Lisinopril and metoprolol are both used to treat hypertension, and the patient's current blood pressure readings suggest that the current treatment regimen may need to be adjusted to achieve better blood pressure control. The patient's blood pressure is severe and requires immediate attention to reduce the risk of cardiovascular complications. 2

From the Research

Concerns for a 53-year-old male on lisinopril and metoprolol with hypertension

• The patient's blood pressure is 191/112, which is significantly higher than the recommended target blood pressure of <140/90 mm Hg 3, 4
• The combination of lisinopril (an angiotensin-converting enzyme inhibitor) and metoprolol (a beta blocker) is a common treatment for hypertension, but the patient's blood pressure is not well controlled 5, 6
• The patient may require an adjustment to their medication regimen, such as an increase in dosage or the addition of another medication, to achieve better blood pressure control 4, 7
• The patient's age and blood pressure level may put them at increased risk for cardiovascular disease, and therefore, it is essential to achieve optimal blood pressure control 3, 4

Potential risks and considerations

• Uncontrolled hypertension can lead to cardiovascular disease, kidney disease, and other complications 3, 4
• The patient's current medication regimen may not be sufficient to control their blood pressure, and alternative treatments or combinations of medications may be necessary 5, 6, 7
• The patient's response to treatment and any potential side effects should be closely monitored to ensure the best possible outcome 3, 4, 7

Treatment options

• Increasing the dosage of lisinopril or metoprolol, or adding another medication, such as amlodipine, to the patient's regimen may be considered to achieve better blood pressure control 5, 6, 7
• Alternative combinations of medications, such as losartan plus amlodipine, may also be effective in controlling the patient's blood pressure 4, 7
• The patient's treatment plan should be individualized based on their specific needs and response to treatment 3, 4, 7