How to manage hypertension in an 80-year-old male on lercanidipine (generic name: lercanidipine is an brand name for a medication with generic name Zaniclipine but more commonly known as a brand name for an calcium channel blocker) 10mg at night and perindopril (an angiotensin-converting enzyme inhibitor) 10mg in the morning, experiencing high blood pressure after electroconvulsive therapy (ECT) sessions twice a week?

Management of Post-ECT Hypertension in an 80-Year-Old Male

For an 80-year-old male with hypertension on lercanidipine 10mg at night and perindopril 10mg in the morning who experiences high blood pressure after electroconvulsive therapy (ECT) sessions, I recommend adding a beta-blocker such as metoprolol or labetalol before ECT sessions to prevent the acute hypertensive response.

Current Medication Assessment

• Patient is currently on:
  • Lercanidipine 10mg at night (calcium channel blocker) 1
  • Perindopril 10mg in the morning (ACE inhibitor) 2
• This combination provides 24-hour blood pressure control through complementary mechanisms 3
• However, ECT is known to cause acute elevations in blood pressure due to sympathetic stimulation 4

Management Strategy for Post-ECT Hypertension

Short-term Management (Before and During ECT Sessions)

1. Pre-ECT Medication Addition:

   • Add a short-acting beta-blocker before ECT sessions 5
   • Options include:
     • Metoprolol 2.5-5mg IV bolus 5-10 minutes before ECT 5
     • Labetalol 0.25-0.5mg/kg IV bolus before ECT 5
   • Beta-blockers are particularly effective for procedure-related hypertension as they block the sympathetic surge 5

2. Monitoring During ECT:

   • Continuous blood pressure monitoring during and immediately after ECT 6
   • Target systolic BP <160/100 mmHg during the procedure 5
   • If BP exceeds 180/120 mmHg, consider this a hypertensive urgency requiring prompt intervention 6

Long-term Management (Optimization of Daily Regimen)

1. Evaluate Current Regimen Effectiveness:

   • Assess if current doses of lercanidipine and perindopril are optimal 5
   • Consider increasing lercanidipine to 20mg if needed 1
   • For patients >80 years, target BP should be 130-139 mmHg systolic 5

2. Consider Adding a Third Agent:

   • If BP remains uncontrolled between ECT sessions, add a thiazide-like diuretic such as indapamide 2.5mg daily 5
   • This three-drug combination (ACE inhibitor + CCB + diuretic) is recommended for resistant hypertension 5

3. Fourth-line Options (if needed):

   • Add spironolactone 25mg daily if renal function is normal and serum K+ <4.5 mmol/L 5
   • Alternative fourth-line agents include eplerenone, doxazosin, or clonidine 5

Special Considerations for Elderly Patients

• For patients ≥80 years, blood pressure targets should be more lenient (systolic 130-139 mmHg) 5
• Monitor for orthostatic hypotension, especially when adding new medications 5
• Start with lower doses of any new medication and titrate slowly 5
• Avoid aggressive BP lowering as it can precipitate renal, cerebral, or coronary ischemia 6

Follow-up Plan

• Reassess BP control after 2-4 weeks of treatment modification 5
• Monitor renal function and electrolytes after adding or adjusting medications 2
• Consider ambulatory blood pressure monitoring to assess 24-hour control 5
• Evaluate for any adverse effects from the medication regimen 7

Common Pitfalls to Avoid

• Avoid short-acting nifedipine for acute BP management (risk of precipitous drops) 6
• Do not lower BP too rapidly after ECT (aim for no more than 25% reduction in the first hour) 6
• Be cautious with beta-blockers in patients with bradycardia, heart block, or decompensated heart failure 5
• Remember that perindopril may increase serum potassium levels, especially when combined with other potassium-sparing medications 2