What is the recommended management for stage 2 hypertension in a 60-year-old?

Management of Stage 2 Hypertension in a 60-Year-Old

For a 60-year-old with stage 2 hypertension, treatment should be initiated to achieve a target systolic blood pressure of less than 150 mmHg to reduce mortality, stroke, and cardiac events. 1

Initial Assessment and Blood Pressure Targets

When managing stage 2 hypertension in a 60-year-old patient, the following approach is recommended:

Blood Pressure Targets

• Primary target: Systolic BP <150 mmHg (strong recommendation, high-quality evidence) 1, 2
• Special populations requiring lower targets (systolic BP <140 mmHg):
  • Patients with history of stroke or TIA 1
  • Patients at high cardiovascular risk 1

Risk Assessment

Evaluate for:

• Previous stroke or TIA
• Cardiovascular risk factors
• Target organ damage
• Comorbid conditions that may influence treatment choice

Treatment Algorithm

Step 1: Lifestyle Modifications

Implement the following non-pharmacological interventions concurrently with medication:

• Weight loss for overweight/obese patients
• DASH diet (Dietary Approaches to Stop Hypertension)
• Sodium restriction (<100 mmol/day or 2.4g/day)
• Regular physical activity (30-60 minutes, 4-7 days/week)
• Alcohol limitation
• Stress management when appropriate

Step 2: Pharmacological Therapy

For stage 2 hypertension, medication should be initiated promptly along with lifestyle modifications.

First-line medication options:

• Thiazide or thiazide-like diuretics
• Angiotensin-converting enzyme inhibitors (ACEIs)
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (CCBs) such as amlodipine 3, 4

Important considerations:

• Most patients will require at least two medications to achieve target BP 5
• ACEIs and ARBs should not be used simultaneously 5
• For Black patients, include either a thiazide diuretic or CCB in the regimen 5
• Amlodipine (CCB) produces effective vasodilation with once-daily dosing, maintaining antihypertensive effect for 24 hours 3
• Monitor blood pressure response approximately 12 hours after dosing and check within 48-72 hours after medication adjustment 2

Step 3: Combination Therapy

If BP remains uncontrolled on initial therapy:

• Add a second agent from a different class
• Consider combination pills to improve adherence
• Preferred combinations include:
  • ACEI/ARB + CCB
  • ACEI/ARB + thiazide diuretic
  • CCB + thiazide diuretic

Step 4: Resistant Hypertension Management

For patients not reaching targets on three medications:

• Add a mineralocorticoid receptor antagonist (spironolactone) 6
• Alternative fourth-line agents: amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 6

Special Considerations

Comorbid Conditions

• Diabetes: ACEI or ARB preferred; if no albuminuria, thiazides or CCBs are also appropriate 7
• Chronic kidney disease with proteinuria: ACEI or ARB plus thiazide diuretic or CCB 5
• Heart failure: Beta-blocker and ACEI/ARB, followed by mineralocorticoid receptor antagonist 5
• Previous stroke: ACEI + diuretic combination preferred 7

Medication Considerations

• Elderly patients may have decreased clearance of amlodipine with resulting increase in drug exposure (40-60%), potentially requiring lower initial doses 3
• Monitor for common adverse effects:
  • CCBs: edema, headache, dizziness
  • ACEIs: cough, hyperkalemia
  • ARBs: dizziness, hyperkalemia
  • Thiazide diuretics: electrolyte disturbances, metabolic effects

Follow-up and Monitoring

• Regular BP monitoring to assess treatment response
• Periodic laboratory evaluation for electrolyte abnormalities and renal function
• Discuss benefits and harms of specific BP targets with the patient
• Assess medication adherence at each visit

Remember that successful hypertension treatment significantly reduces cardiovascular disease risk, with a 10 mmHg reduction in SBP decreasing CVD events by approximately 20-30% 4.