What are the first-line antihypertensive medications for a 63-year-old woman with hypertension?

First-Line Antihypertensive Medications for a 63-Year-Old White Woman

For a 63-year-old white woman with hypertension, the first-line antihypertensive medications should be a thiazide diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). 1

Initial Medication Selection

• Thiazide diuretics (particularly chlorthalidone) are recommended as effective first-line agents with strong evidence for reducing cardiovascular events and mortality in older adults 1, 2
• Calcium channel blockers (particularly dihydropyridines like amlodipine) are equally effective first-line options, especially for older patients 1, 3
• ACE inhibitors or ARBs are also appropriate first-line options, with ARBs potentially being better tolerated due to lower incidence of cough 1
• Beta-blockers are not recommended as first-line therapy unless the patient has specific comorbidities such as coronary artery disease or heart failure 1, 3

Age-Specific Considerations

• For patients over 60 years of age, the International Society of Hypertension guidelines suggest that dihydropyridine CCBs or thiazide diuretics may be more effective as initial therapy 1
• European guidelines specifically note that drug treatment for elderly patients with systolic-diastolic or isolated systolic hypertension can be initiated with thiazide diuretics, calcium antagonists, ACE inhibitors, or ARBs 1
• Initial doses and subsequent dose titration should be more gradual in older patients due to increased risk of adverse effects 1, 3

Evidence-Based Recommendations

• The ALLHAT trial demonstrated that chlorthalidone (a thiazide diuretic) was as effective as amlodipine (a CCB) and lisinopril (an ACE inhibitor) in preventing coronary heart disease and was superior in preventing heart failure 2
• For white patients, ACE inhibitors and ARBs have shown good efficacy, while some evidence suggests they may be less effective in Black patients 1, 4
• Dihydropyridine CCBs have demonstrated particular efficacy in isolated systolic hypertension, which is common in older adults 3, 5

Treatment Algorithm

1. Start with a single agent at a lower dose: thiazide diuretic (preferably chlorthalidone), CCB (amlodipine), ACEI (lisinopril), or ARB 1
2. If blood pressure is not controlled within 2-4 weeks, either increase the dose of the initial medication or add a second agent from a different class 1
3. If combination therapy is needed, effective combinations include:
   • ACEI/ARB + CCB
   • ACEI/ARB + thiazide diuretic
   • CCB + thiazide diuretic 1

Monitoring and Follow-up

• Monitor blood pressure control, aiming for a target of <130/80 mmHg if tolerated 1
• For elderly patients, blood pressure should be measured in both sitting and standing positions to assess for orthostatic hypotension 1, 3
• Follow up within 2-4 weeks after medication changes to assess efficacy and adverse effects 1
• Monitor for electrolyte abnormalities, particularly with diuretic therapy 1

Common Pitfalls to Avoid

• Avoid rapid dose escalation in elderly patients, which can increase risk of adverse effects 1, 3
• Don't use beta-blockers as first-line therapy unless specific indications exist (coronary artery disease, heart failure) 1
• Don't ignore standing blood pressure measurements in elderly patients due to increased risk of orthostatic hypotension 1, 3
• Avoid discontinuing effective and well-tolerated therapy when a patient reaches advanced age 1, 3