What is a suitable weight loss plan with medication options for a 59-year-old male with hypertension (HTN) and coronary artery disease (CAD)?

Weight Loss Plan for 59-Year-Old Male with HTN and CAD

For a 59-year-old male with hypertension and coronary artery disease, a comprehensive weight loss plan should include lifestyle modifications with potential pharmacotherapy, targeting a 10% weight reduction from baseline to improve cardiovascular outcomes and reduce mortality risk. 1

Lifestyle Modifications

Dietary Approach

• Implement the DASH (Dietary Approaches to Stop Hypertension) eating plan, which is rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat content, providing 8-14 mmHg reduction in systolic blood pressure 1, 2
• Restrict sodium intake to less than 2.4g per day (6g sodium chloride), which can reduce systolic blood pressure by 2-8 mmHg 1, 2
• Increase potassium intake through consumption of 8-10 servings of fruits and vegetables daily 2
• Include 2-3 servings of low-fat dairy products daily 2
• Aim for a caloric deficit of approximately 500-1000 calories per day to achieve gradual weight loss 1
• Consider a high-protein/low-glycemic load diet for weight maintenance following initial weight loss 3

Physical Activity

• Engage in regular aerobic physical activity for 30-60 minutes on most days of the week (minimum 5 days), preferably all days 1
• Include moderate-intensity activities such as brisk walking, which can reduce systolic blood pressure by 4-9 mmHg 1
• Add resistance training 2 days per week as a supplement to aerobic activity 1
• For this high-risk patient (with CAD), consider a medically supervised exercise program initially 1

Alcohol Moderation

• Limit alcohol consumption to no more than 2 drinks per day (24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) 1
• This can provide a 2-4 mmHg reduction in systolic blood pressure 1, 2

Weight Loss Goals

• Target initial weight loss of approximately 10% from baseline 1, 4
• Aim for a BMI between 18.5-24.9 kg/m² 1
• Waist circumference goal should be less than 40 inches (measured horizontally at the iliac crest) 1
• Even modest weight loss of 4.5 kg (10 lbs) can significantly reduce blood pressure 1
• Intentional weight loss (through programmed lifestyle changes) is associated with improved cardiovascular outcomes in patients with CAD, unlike observational weight loss 5

Pharmacotherapy Options

For patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities (such as hypertension and CAD) who have not achieved adequate weight loss with lifestyle modifications alone:

• Avoid sympathomimetic agents such as phentermine or phentermine/topiramate in patients with cardiovascular disease 1
• Safer alternatives for this patient with HTN and CAD include:
  • Orlistat (lipase inhibitor) - can achieve approximately 3% weight loss at 1 year compared to placebo 1
  • GLP-1 analogs (e.g., liraglutide 3.0 mg) - can achieve approximately 5.4% weight loss at 56 weeks compared to placebo 1
  • Consider medications that have favorable effects on both weight and cardiovascular risk factors 1, 6

Monitoring and Follow-up

• Evaluate adherence to the weight loss plan at each visit 1
• Monitor blood pressure regularly, with a target of <130/80 mmHg for patients with CAD 1
• If using weight loss medications, assess efficacy and safety monthly for the first 3 months, then at least every 3 months 1
• Consider discontinuation of weight loss medication if less than 5% weight loss is achieved at 12 weeks 1
• Monitor lipid profile, as weight loss can improve dyslipidemia 3
• Track inflammatory markers (e.g., C-reactive protein) as weight loss can reduce low-grade inflammation 3

Special Considerations for CAD and HTN

• Ensure appropriate antihypertensive medication management alongside weight loss efforts 1
• For patients with CAD, RAS blockers (ACE inhibitors or ARBs) and beta-blockers are recommended as first-line antihypertensive agents 1, 2
• Target LDL-C levels <70 mg/dL (1.8 mmol/L) in patients with established CAD 1
• Continue antiplatelet therapy as indicated for secondary prevention 1

By implementing this comprehensive weight loss plan, the patient can expect improvements in blood pressure control, lipid profile, and overall cardiovascular risk, potentially reducing morbidity and mortality related to both hypertension and coronary artery disease 1, 5.