What is the recommended management for an 84-year-old male with hypertension, refusing medication, and presenting with weakness on the right side of his body, fluctuating blood pressure in the range of severe hypertension, and magnetic resonance imaging (MRI) showing high-grade stenosis of the distal M1 segment, currently taking aspirin (acetylsalicylic acid) 315 mg daily?

Management of 84-Year-Old Male with Hypertension, Cerebrovascular Stenosis, and Right-Sided Weakness

The recommended management for this patient includes immediate initiation of antihypertensive therapy with a calcium channel blocker (CCB) and an angiotensin receptor blocker (ARB), along with continued aspirin therapy and urgent measures to improve medication adherence. 1, 2

Immediate Blood Pressure Management

• Target blood pressure: <130/80 mmHg, which is recommended for patients with a history of stroke or TIA 1, 2
• First-line medication regimen:
  • Calcium channel blocker (e.g., amlodipine 5-10 mg daily) - preferred in elderly patients and those with cerebrovascular disease 1, 2
  • Angiotensin receptor blocker (e.g., losartan 50 mg daily) - shown to reduce stroke risk by 25% compared to other antihypertensives 3
  • Continue aspirin 325 mg daily for secondary stroke prevention

Addressing Medication Non-Adherence

• Implement strategies to improve adherence:
  • Simplify regimen with once-daily fixed-dose combination pills 4
  • Educate patient about stroke risk with uncontrolled hypertension
  • Consider family/caregiver involvement in medication administration
  • Schedule frequent follow-up visits (every 2-4 weeks initially) 2
  • Consider home blood pressure monitoring to reinforce importance of control 1

Cerebrovascular Disease Management

• Maintain current antiplatelet therapy:

  • Continue aspirin 325 mg daily (current dose is appropriate)
  • Do not add additional antiplatelet agents unless specifically indicated

• Neurological follow-up:

  • Arrange for follow-up imaging to monitor cerebrovascular stenosis
  • Consider neurology consultation for evaluation of right-sided weakness

Escalation Plan for Resistant Hypertension

If blood pressure remains uncontrolled despite adherence to the initial regimen:

1. Add a thiazide diuretic (e.g., chlorthalidone 12.5-25 mg daily) 1, 2
2. If still uncontrolled, consider adding:
   • Spironolactone 25 mg daily (most effective fourth agent) 2
   • Or beta-blocker if spironolactone is contraindicated 1

Lifestyle Modifications

• Dietary recommendations:

  • Sodium restriction (<2 grams/day)
  • DASH diet pattern
  • Limit alcohol consumption
  • Increase potassium intake through fruits and vegetables

• Physical activity:

  • Prescribe appropriate exercise based on mobility limitations from right-sided weakness
  • Start with supervised sessions if available

Monitoring Plan

• Short-term monitoring:

  • Blood pressure check weekly until controlled
  • Laboratory monitoring for electrolytes and kidney function within 1-2 weeks of starting medications
  • Home blood pressure monitoring twice daily

• Long-term monitoring:

  • Monthly visits until stable, then every 3 months
  • Annual neuroimaging to assess cerebrovascular stenosis
  • Regular assessment of medication adherence

Special Considerations for This Patient

• Advanced age (84 years): Start medications at lower doses and titrate more slowly, but still aim for target BP <130/80 mmHg 1, 2

• Cerebrovascular disease: Antihypertensive treatment should be initiated immediately for patients with TIA or stroke history 1

• Medication refusal: Consider involving social work, family members, or psychiatric consultation if medication refusal persists despite education about risks

Pitfalls and Caveats

• Avoid rapid blood pressure reduction which could compromise cerebral perfusion in a patient with cerebrovascular stenosis
• Don't use ACE inhibitors and ARBs in combination due to increased risk of adverse events without additional benefit 1
• Don't delay treatment while waiting for perfect adherence - start medications and address adherence simultaneously
• Avoid assuming that aspirin alone is sufficient for secondary stroke prevention without adequate blood pressure control
• Don't overlook the need for regular monitoring of electrolytes and kidney function, especially when adding diuretics or spironolactone

This management approach prioritizes immediate blood pressure control to reduce the risk of further cerebrovascular events while addressing the challenges of medication adherence in an elderly patient with established cerebrovascular disease.