What is a good adjunct medication for an elderly lady with hypertension on ramipril with a wide pulse pressure?

Managing Wide Pulse Pressure in an Elderly Patient on Ramipril

For an elderly lady with hypertension on ramipril 20mg daily with a wide pulse pressure (173/73), a calcium channel blocker such as amlodipine is the most appropriate adjunct medication to add to her regimen. 1

Rationale for Calcium Channel Blocker Addition

The wide pulse pressure (100 mmHg) in this patient indicates arterial stiffness, which is common in elderly patients. This clinical presentation requires careful consideration of medication choice:

• Calcium channel blockers (CCBs) are specifically recommended for elderly patients (≥55 years) as first-line or add-on therapy according to American College of Cardiology and European Society of Cardiology guidelines 1
• CCBs are particularly effective at reducing systolic blood pressure in elderly patients with isolated systolic hypertension 2
• The patient is already on maximum dose ramipril (20mg), which is an ACE inhibitor, making a CCB the logical next agent to add

Benefits of Calcium Channel Blockers in This Case

1. Superior Systolic BP Reduction: Studies show calcium channel blockers produce approximately 15 mmHg reduction in systolic BP in elderly patients, comparable to diuretics (13 mmHg) and superior to ACE inhibitors (8 mmHg) 2

2. Complementary Mechanism: Adding a CCB to an ACE inhibitor creates a synergistic effect:

   • ACE inhibitors block the renin-angiotensin system
   • CCBs work through direct arterial vasodilation
   • This combination is particularly effective for isolated systolic hypertension 1

3. Safety Profile in Elderly: Amlodipine has demonstrated:

   • Good tolerability in elderly patients 3, 4
   • Similar incidence of adverse events across age groups 3
   • Once-daily dosing convenience 3

Specific Recommendation

Start with amlodipine 2.5mg daily and titrate up to 5-10mg daily as needed and tolerated. Morning dosing may provide slight advantages over evening dosing 3.

Monitoring Considerations

• Postural Hypotension: The wide pulse pressure with normal diastolic BP (73 mmHg) indicates stiff arteries. Monitor for orthostatic hypotension, especially given the patient's age 5
• Ankle Edema: Watch for peripheral edema, a common side effect of calcium channel blockers
• Electrolytes: Regular monitoring of electrolytes is recommended when adding a new antihypertensive 5

Alternative Options

If amlodipine is not tolerated or contraindicated:

• Thiazide Diuretic: Could be considered as an alternative, as diuretics also show good efficacy in reducing systolic BP in elderly patients 2
• Combination Products: Fixed-dose combinations of telmisartan/amlodipine have shown efficacy in difficult-to-control hypertension, but would require switching from ramipril to telmisartan 6

Target Blood Pressure

For elderly patients (≥65 years), aim for a systolic BP target of <130 mmHg if tolerated, while carefully monitoring for adverse effects 1.