What is the best treatment approach for a 73-year-old female with asymptomatic hypertension and a blood pressure of 185/100 mmHg?

Treatment of Asymptomatic Hypertension in a 73-Year-Old Female

For a 73-year-old female with asymptomatic hypertension and blood pressure of 185/100 mmHg, immediate initiation of antihypertensive medication is required, with a thiazide diuretic such as chlorthalidone as first-line therapy, followed by addition of an ACE inhibitor or ARB if needed to achieve target blood pressure. 1

Initial Assessment and Classification

This patient presents with:

• Grade 2 hypertension (BP ≥160/100 mmHg)
• Asymptomatic presentation
• Normal laboratory values
• Advanced age (73 years)

According to the International Society of Hypertension (ISH) 2020 guidelines, this blood pressure reading requires immediate drug treatment along with lifestyle modifications 1.

Treatment Algorithm

Step 1: Immediate Pharmacotherapy

• Start with a low-dose thiazide or thiazide-like diuretic (e.g., chlorthalidone 12.5 mg daily)
  • Thiazide diuretics are the only class proven to reduce cardiovascular events in elderly patients with isolated systolic hypertension 2
  • Low-dose thiazides minimize metabolic side effects while maintaining efficacy 3

Step 2: If BP Target Not Achieved Within 4 Weeks

• Add an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily)
  • For non-Black patients, this combination is recommended by the ISH guidelines 1
  • Lisinopril is indicated for treatment of hypertension to lower blood pressure and reduce risk of fatal and non-fatal cardiovascular events 4

Step 3: If BP Target Still Not Achieved

• Add a dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily)
• Consider increasing doses of medications before adding another agent

Step 4: If BP Remains Uncontrolled

• Add spironolactone (25 mg daily) or other fourth-line agent
• Consider referral to a hypertension specialist if BP remains uncontrolled 1

Blood Pressure Targets

For this 73-year-old patient:

• Target BP: <140/90 mmHg initially
• Aim to reduce BP by at least 20/10 mmHg from baseline 1
• Consider individualizing target based on frailty and comorbidities
• The European Society of Cardiology recommends a target of 130-139/80 mmHg for patients 65-79 years 5

Lifestyle Modifications (Concurrent with Medication)

Recommend the following lifestyle changes:

• DASH-style eating pattern with reduced sodium (<2,300 mg/day)
• Increased potassium intake through fruits and vegetables
• Regular physical activity appropriate for age and ability
• Weight loss if indicated
• Moderation of alcohol intake (≤1 drink/day for women)
• Smoking cessation if applicable 1, 5

Monitoring and Follow-up

• Schedule follow-up within 4 weeks to assess BP control
• Monitor serum electrolytes, creatinine, and uric acid within 2-4 weeks of starting therapy
• Assess for orthostatic hypotension, especially given patient's age
• Measure BP in both sitting and standing positions to detect postural hypotension 1
• Aim to achieve target BP within 3 months 1

Important Considerations for Elderly Patients

• Start with lower doses and titrate more gradually due to increased risk of adverse effects
• Monitor for orthostatic hypotension which is more common in elderly patients
• Consider home BP monitoring to detect variability and confirm office readings
• Be vigilant for drug interactions if the patient is on multiple medications
• Avoid rapid BP reduction which may lead to cerebral hypoperfusion 1

Common Pitfalls to Avoid

1. Therapeutic inertia - Failing to intensify treatment when BP remains uncontrolled
2. White coat hypertension - Consider home or ambulatory BP monitoring to confirm diagnosis
3. Orthostatic hypotension - Always measure BP in both sitting and standing positions
4. Medication non-adherence - Use once-daily dosing and fixed-dose combinations when possible
5. Overlooking secondary causes - Consider screening if BP is resistant to treatment

This approach prioritizes mortality and morbidity reduction through evidence-based medication selection while accounting for the patient's age and asymptomatic status.