Which medication should be adjusted due to the patient's symptoms of lightheadedness, dizziness, and fatigue, likely caused by hypotension?

Management of Hypotension in a 90-Year-Old Patient with Cardiovascular Disease

Based on the patient's symptoms of lightheadedness, dizziness, fatigue, and documented hypotension (BP 85/59), lisinopril should be reduced or discontinued as the first intervention.

Assessment of Current Symptoms

• The patient presents with constant dizziness, lightheadedness affecting her eyes, inability to keep eyes open during dizzy episodes, fatigue, documented hypotension (85/59), and episodes of falling asleep for 2-3 hours 1
• These symptoms are consistent with symptomatic orthostatic hypotension, which is defined as a reduction in systolic BP of at least 20 mmHg or diastolic BP of at least 10 mmHg within 3 minutes of standing 1
• The symptoms are interfering with activities of daily living and are not improving despite reduction in isosorbide mononitrate dosage 1

Medication Analysis and Recommendations

Primary Target for Adjustment:

• Lisinopril 20 mg twice daily should be reduced or discontinued as it is the most likely cause of the patient's symptomatic hypotension 1
• ACE inhibitors like lisinopril commonly cause hypotension, especially in elderly patients and those on multiple cardiovascular medications 2
• The patient is on a high dose (20 mg twice daily), which exceeds the typical starting dose for heart failure (5 mg once daily) 2

Rationale for Targeting Lisinopril:

• When symptomatic hypotension occurs with dizziness and lightheadedness, the European Journal of Heart Failure recommends reconsidering the need for ACE inhibitors before other vasodilators 1
• The American Heart Association guidelines specifically state that if hypotension is accompanied by clinical evidence of hypoperfusion, ACE inhibitor therapy should be decreased or discontinued pending further evaluation 1
• Elderly patients (≥90 years) are particularly susceptible to hypotension from ACE inhibitors due to decreased baroreceptor response and increased drug sensitivity 3

Secondary Considerations:

• If reducing lisinopril is insufficient:
  • Consider reducing bisoprolol (10 mg daily) as beta-blockers can also cause bradycardia and hypotension 1, 4, 3
  • Isosorbide mononitrate (already reduced) may need further adjustment or discontinuation as nitrates are potent vasodilators 1

Implementation Plan

1. First step: Reduce lisinopril to 5-10 mg once daily or discontinue completely based on clinical response 1, 2
2. Monitoring: Check orthostatic blood pressures (lying and standing) at follow-up visits to document improvement 1
3. If symptoms persist: Consider further reducing or discontinuing bisoprolol, especially if bradycardia is present (heart rate <50 bpm) 1, 4, 3
4. Medication timing: If partial doses are maintained, administer beta-blockers and ACE inhibitors at different times of the day to minimize hypotensive effects 1

Special Considerations for This Patient

• Advanced age (90 years) increases susceptibility to medication-induced hypotension 1, 3
• Multiple cardiovascular conditions and medications create higher risk for drug interactions and adverse effects 1
• The patient's extensive vascular disease (carotid stenosis, CAD, PAD) may impair autoregulation of blood pressure 1, 5
• Ambulatory monitoring with a cane indicates mobility concerns, which increases fall risk with hypotension 1

Potential Pitfalls and Precautions

• Abrupt withdrawal of beta-blockers should be avoided; if bisoprolol needs adjustment, it should be tapered gradually 1, 3
• Monitor for worsening heart failure symptoms if cardiovascular medications are reduced 1
• Consider that the patient's symptoms could have multiple causes beyond medication effects, including carotid disease and cardiac arrhythmias 1, 6
• The patient's telemonitoring results show pauses and SVT runs, which could contribute to symptoms and should be monitored during medication adjustments 7, 3