Is it worth increasing anti-hypertensive medications in an 81-year-old patient with HTN, HFrEF, and CKD 3a, with a recent 7-day average blood pressure of 141/79, who is currently taking bisoprolol fumarate (5mg daily)?

Management of Hypertension in an 81-Year-Old Patient with HFrEF and CKD

Increasing antihypertensive medication is not recommended for this 81-year-old patient with a 7-day average blood pressure of 141/79 mmHg, as this BP is reasonably controlled given the patient's age and comorbidities.

Current Blood Pressure Status Assessment

The patient's current 7-day average blood pressure of 141/79 mmHg should be evaluated in the context of:

1. Age consideration: At 81 years old, slightly higher systolic BP may be tolerated
2. Multiple comorbidities: HFrEF (EF 35-40%), CAD s/p CABG, CKD 3a
3. Current antihypertensive regimen: Already on multiple agents
   • Entresto 97-103 mg BID (sacubitril/valsartan)
   • Bisoprolol 5 mg daily
   • Empagliflozin 10 mg daily (which has BP-lowering effects)

Guideline-Based Recommendations

According to the 2017 ACC/AHA Hypertension Guidelines 1:

• For most adults, the BP target is <130/80 mmHg
• However, treatment decisions should consider risk-benefit balance, especially in older adults
• In patients with multiple comorbidities and advanced age, a more conservative approach may be warranted

For patients with heart failure with reduced ejection fraction (HFrEF), the guidelines recommend 1:

• Beta-blockers (specifically bisoprolol, carvedilol, or metoprolol succinate)
• ACE inhibitors/ARBs or ARNI (Entresto)
• Mineralocorticoid receptor antagonists when appropriate

Risk-Benefit Analysis for Increasing Antihypertensive Therapy

Potential Benefits:

• Further reduction in cardiovascular risk if BP is lowered closer to 130/80 mmHg

Potential Risks:

• Hypotension: Elderly patients are more susceptible to orthostatic hypotension
• Medication burden: Already on multiple medications
• Renal function: CKD 3a could worsen with aggressive BP lowering
• Falls risk: Increased risk in elderly patients with lower BP targets

Specific Considerations for This Patient

1. Current antihypertensive regimen is appropriate:

   • Entresto (sacubitril/valsartan) - optimal for HFrEF
   • Bisoprolol - cardioselective beta-blocker appropriate for HFrEF
   • Empagliflozin - beneficial for both HFrEF and CKD

2. Bisoprolol considerations:

   • Current dose (5 mg) is moderate; maximum dose is 10 mg daily
   • Bisoprolol has balanced clearance (renal and hepatic), making it appropriate for patients with CKD 2
   • Studies show bisoprolol preserves renal function during medium-term treatment 3

3. Blood pressure target:

   • The current BP (141/79 mmHg) is only slightly above the general target
   • For an 81-year-old with multiple comorbidities, this level may represent an appropriate balance between risk reduction and avoiding adverse effects

Decision Algorithm

1. Is the current BP dangerously elevated? No - 141/79 mmHg is only mildly elevated
2. Is the patient experiencing symptoms of hypertension? Not indicated in the history
3. Is the patient at high risk of imminent cardiovascular events? Already optimally treated for HFrEF
4. Would the risks of more aggressive treatment outweigh benefits? Yes - risk of hypotension, falls, and worsening renal function likely outweigh marginal benefits

Monitoring Recommendations

• Continue monitoring home blood pressure readings
• Reassess BP and medication tolerance at next follow-up visit
• Monitor renal function and electrolytes regularly
• If systolic BP consistently rises above 150 mmHg, reconsider medication adjustment

Common Pitfalls to Avoid

• Overtreatment: Aggressive BP lowering in elderly patients can lead to falls, cognitive impairment, and decreased quality of life
• Target fixation: Focusing solely on BP numbers rather than overall patient well-being
• Medication burden: Adding more medications without considering cumulative side effects and interactions
• Ignoring diastolic BP: The patient's diastolic BP is well-controlled at 79 mmHg; excessive lowering could compromise coronary perfusion

In conclusion, the patient's current antihypertensive regimen appears appropriate, and increasing medication is not recommended at this time given the modest BP elevation, advanced age, and multiple comorbidities.