What is the next step in managing a patient with stage 2 hypertension on Lisinopril (Angiotensin-Converting Enzyme Inhibitor) 5 mg with a blood pressure reading of 138/78 and orthostatic hypotension?

Management of Stage 2 Hypertension with Orthostatic Hypotension

For a patient with stage 2 hypertension on lisinopril 5 mg with a blood pressure of 138/78 and orthostatic hypotension, the recommended next step is to increase the lisinopril dose to 10-20 mg daily while carefully monitoring for worsening orthostatic symptoms. 1, 2

Assessment of Current Situation

• The patient's current BP of 138/78 mmHg is not at target for stage 2 hypertension, which should be <130/80 mmHg according to the 2017 ACC/AHA guidelines 1
• The presence of orthostatic hypotension complicates management but does not preclude appropriate BP control 3
• The current lisinopril dose of 5 mg is at the lower end of the therapeutic range; FDA labeling recommends 10-40 mg daily for hypertension 2

Next Steps in Management

1. Optimize ACE Inhibitor Therapy

• Increase lisinopril dose to 10 mg daily as the next step 2
  • The FDA-approved dosage range for lisinopril in hypertension is 10-40 mg per day administered as a single daily dose 2
  • Lisinopril reaches peak serum concentrations 6-8 hours after oral dosing with an antihypertensive effect that lasts at least 24 hours 4

2. Monitor for Orthostatic Hypotension

• Schedule follow-up within 2-4 weeks to assess:

  • BP response to increased medication dose 1
  • Worsening of orthostatic symptoms 1
  • Electrolytes and renal function 1

• Orthostatic BP measurements should be performed at each visit to track changes 3

3. Consider Additional Therapy if Needed

• If BP remains above target after optimizing lisinopril dose, add a thiazide-like diuretic (preferably chlorthalidone 12.5-25 mg) 1

  • The combination of ACE inhibitor and thiazide diuretic provides complementary mechanisms of action 1
  • However, use caution with diuretics in patients with orthostatic hypotension 1

• If orthostatic hypotension worsens with medication adjustments, consider:

  • Splitting the daily dose of antihypertensive medications 3
  • Administering medications at bedtime 3
  • Using longer-acting agents to minimize BP fluctuations 4

Special Considerations for Orthostatic Hypotension

• Review and potentially remove aggravating factors:

  • Non-antihypertensive medications that may worsen orthostasis 3
  • Excessive sodium restriction 3
  • Dehydration 2

• Patient education regarding orthostatic symptoms:

  • Rising slowly from sitting or lying positions 2
  • Maintaining adequate hydration 2
  • Reporting symptoms of light-headedness or dizziness 2

Follow-up Plan

• Reassess BP control and orthostatic symptoms within 1 month 1
• For patients with stage 2 hypertension, the goal is to achieve target BP within 3 months 1
• If BP remains uncontrolled or orthostatic symptoms worsen despite medication adjustments, consider referral to a hypertension specialist 1

Potential Pitfalls and Caveats

• Do not discontinue antihypertensive therapy solely due to the presence of orthostatic hypotension; instead, optimize the regimen 3
• Avoid rapid upward titration of antihypertensive medications in patients with orthostatic symptoms 1
• Be cautious with initiating combination therapy in patients with orthostatic hypotension 1
• Monitor for signs of acute kidney injury when increasing ACE inhibitor dose, especially if adding diuretics 2
• Remember that orthostatic hypotension may be a sign of volume depletion or autonomic dysfunction that requires further evaluation 3