Can I start telmisartan (an angiotensin II receptor antagonist) 40 mg once daily in a 75-year-old male with hypertension (blood pressure 160/80 mmHg), productive cough, and significant ECG abnormalities including left axis deviation, left ventricular hypertrophy, and left bundle branch block?

Telmisartan for Hypertension in a 75-Year-Old with Productive Cough and ECG Abnormalities

Telmisartan 40 mg once daily is an appropriate initial treatment choice for this 75-year-old male with a blood pressure of 160/80 mmHg, productive cough, and ECG abnormalities showing left axis deviation, left ventricular hypertrophy, and left bundle branch block. 1, 2

Rationale for Treatment

1. Blood Pressure Classification and Goals:

   • BP of 160/80 mmHg in a 75-year-old qualifies as Stage 2 hypertension requiring prompt intervention
   • For elderly patients (≥65 years), a target blood pressure of <130 mmHg is recommended if tolerated 1
   • The productive white cough that worsens when lying down suggests a non-ACE inhibitor related etiology, making an ARB like telmisartan appropriate

2. Medication Selection Considerations:

   • Telmisartan is an angiotensin II receptor antagonist that selectively inhibits type 1 angiotensin II receptors 3
   • The usual starting dose of telmisartan is 40 mg once daily, which is appropriate for elderly patients with no initial dosage adjustment necessary 2
   • Most antihypertensive effect appears within 2 weeks with maximal reduction generally attained after 4 weeks 2

3. ECG Abnormalities and Cardiac Considerations:

   • The patient's ECG shows left ventricular hypertrophy and left bundle branch block, suggesting target organ damage
   • ARBs like telmisartan are beneficial in patients with left ventricular hypertrophy 1
   • For patients with heart failure or cardiovascular risk factors, ARBs are recommended as part of the treatment regimen 1

Efficacy and Safety Profile

• Telmisartan 40 mg produces mean reductions in systolic and diastolic blood pressure of approximately 9-13/6-8 mmHg 2
• Telmisartan provides effective 24-hour blood pressure control, including during the early morning hours when cardiovascular events are more common 4
• Telmisartan has a tolerability profile similar to placebo in clinical studies 5
• Unlike ACE inhibitors, ARBs like telmisartan have a significantly lower incidence of dry cough (3% vs 7% for lisinopril) 6

Monitoring and Follow-up

• Blood pressure should be reassessed in 1 month after initiating therapy 1
• Electrolytes and renal function should be checked 2-4 weeks after starting therapy 1
• Monitor for orthostatic hypotension, especially in elderly patients 2
• If blood pressure remains uncontrolled after 4 weeks, consider:
  • Increasing telmisartan dose to 80 mg daily
  • Adding a thiazide-like diuretic (preferably chlorthalidone) if further BP reduction is needed 1

Cautions and Considerations

• The productive cough is likely unrelated to medication (since patient is not currently on ACE inhibitors) and should be evaluated separately
• ARBs should be used with caution in patients with bilateral renal artery stenosis 1
• Telmisartan can be administered with or without food 2
• The presence of left ventricular hypertrophy and left bundle branch block indicates target organ damage, supporting the need for prompt and effective BP control

In conclusion, telmisartan 40 mg once daily is an appropriate initial treatment for this elderly patient with hypertension, providing effective 24-hour blood pressure control with a favorable side effect profile that avoids exacerbating the existing cough.