What is the best initial medication for a 75-year-old female with stage 2 hypertension (blood pressure 198/80 mmHg) and normal laboratory results?

Best Initial Medication for Stage 2 Hypertension in a 75-Year-Old Female

For a 75-year-old female with stage 2 hypertension (198/80 mmHg) and normal laboratory results, a thiazide diuretic, particularly chlorthalidone, is the recommended first-line medication due to its superior efficacy in preventing heart failure, a common condition in older adults. 1

First-Line Medication Options

• Thiazide diuretics are particularly desirable for older adults because of their proven effectiveness in preventing heart failure, which is increasingly common in this age group 1
• Chlorthalidone is specifically recommended among thiazide diuretics for elderly patients with hypertension 1, 2
• Other first-line options include calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) 1, 3

Rationale for Thiazide Diuretic as First Choice

• The 2017 hypertension guidelines recommend initiating antihypertensive drug therapy with thiazide diuretics, calcium channel blockers, or ACEIs/ARBs 1
• For this elderly patient with markedly elevated systolic blood pressure (198 mmHg), thiazide diuretics have demonstrated superior outcomes in preventing cardiovascular events 1, 2
• The target blood pressure goal should be <130/80 mmHg according to current guidelines 3, 2

Dosing Considerations

• Start with a low dose and titrate gradually to minimize adverse effects 1
• For elderly patients, careful monitoring is essential as they are more likely to experience serious adverse events with antihypertensive medications 1
• Despite higher risk of adverse events, intensive blood pressure control in SPRINT did not increase orthostatic hypotension, syncope, or falls in those aged 75 and older 1

Medication-Specific Considerations

• If a calcium channel blocker like amlodipine is chosen as an alternative, the usual initial dose is 5 mg once daily, with a maximum of 10 mg once daily 4
• For elderly patients starting amlodipine, a lower initial dose of 2.5 mg may be appropriate 4, 5
• Amlodipine has demonstrated effectiveness in lowering systolic blood pressure in elderly patients, with mean reductions of 25/16 mmHg in those ≥65 years of age 5

Monitoring and Follow-up

• Recheck blood pressure within 4 weeks of medication initiation 3
• Monitor for potential side effects, particularly electrolyte disturbances with thiazide diuretics 3, 2
• Target blood pressure control should be achieved within 3 months 3

Important Caveats

• Avoid alpha₁ blockers and central alpha₂ agonists as initial therapy in older adults due to higher likelihood of adverse effects 1
• Beta-blockers are less effective than diuretics for prevention of stroke and cardiovascular events in elderly patients 1
• If blood pressure remains uncontrolled after initial therapy, adding a medication from a different class (e.g., adding a calcium channel blocker to a thiazide diuretic) is recommended 3, 2