Can this patient be given anti-hypertension medication, specifically a beta-blocker (e.g. metoprolol succinate) or an angiotensin-converting enzyme inhibitor (ACEi) (e.g. lisinopril)?

Can This Patient Be Given Anti-Hypertension Medication?

Yes, both beta-blockers (metoprolol succinate) and ACE inhibitors (lisinopril) can be given to patients with hypertension, but the choice depends critically on specific comorbidities and contraindications that must be evaluated first.

Initial Assessment Requirements

Before prescribing either medication, you must identify:

• Absolute contraindications to beta-blockers: Active asthma or severe bronchospastic disease, decompensated heart failure, severe bradycardia, high-degree heart block, or acute pheochromocytoma without alpha-blockade 1
• Absolute contraindications to ACE inhibitors: Pregnancy, history of angioedema, bilateral renal artery stenosis 2
• Blood pressure threshold for treatment: Pharmacological therapy is indicated when BP ≥130/80 mmHg with confirmed hypertension diagnosis 3

Comorbidity-Directed Medication Selection

The ACC/AHA guidelines provide clear direction based on specific conditions 3:

Favor Beta-Blockers (Metoprolol Succinate) When:

• Stable ischemic heart disease - GDMT beta-blockers (carvedilol, metoprolol succinate, bisoprolol) are specifically recommended 3
• Post-MI or acute coronary syndrome - Beta-blockers are guideline-directed medical therapy 3
• Chronic stable angina - Beta-blockers are first-line, with DHP calcium antagonists added for additional BP control 3
• Aortic disease - Beta-blockers are favored in patients with thoracic aorta disease 3
• Heart failure with reduced ejection fraction - GDMT beta-blockers are recommended 3

Favor ACE Inhibitors (Lisinopril) When:

• Chronic kidney disease - ACEI or ARB are preferred (ARB if ACEI not tolerated) 3
• Diabetes with albuminuria - ACEI or ARB are specifically recommended 3
• Heart failure with preserved EF - Add ACEI or ARB with beta-blocker for incremental BP control 3
• Secondary stroke prevention - Thiazide, ACEI, ARB or combinations are recommended 3

Avoid Beta-Blockers When:

• Aortic insufficiency - Avoid drugs that slow heart rate including beta-blockers and non-DHP calcium antagonists 3
• Heart failure with reduced EF - Avoid non-DHP calcium antagonists, but GDMT beta-blockers are actually recommended 3
• Active bronchospastic disease - Patients should generally not receive beta-blockers, though beta-1 selective agents may be used cautiously with readily available bronchodilators 1

Critical Safety Considerations

For Beta-Blockers (Metoprolol):

• Never abruptly discontinue in patients with coronary artery disease - severe exacerbation of angina, MI, and ventricular arrhythmias can occur; taper over 1-2 weeks 1
• Monitor for bradycardia - including sinus pause, heart block, and cardiac arrest; patients with first-degree AV block or conduction disorders are at increased risk 1
• Diabetes management - Beta-blockers may mask tachycardia from hypoglycemia, though other manifestations remain; diabetes is no longer an absolute contraindication with beta-1 selective agents 1, 4
• Pheochromocytoma - Must give with alpha-blocker, and only after alpha-blocker initiated 1

For ACE Inhibitors (Lisinopril):

• Monitor serum potassium - Mean increase approximately 0.1 mEq/L, but 15% of patients have increases >0.5 mEq/L 2
• Anticipate first-dose hypotension - Especially in volume/salt-depleted patients 2
• Renal function monitoring - ACE inhibitors increase renal blood flow but require monitoring in CKD 5

Efficacy Considerations

• Beta-blockers as monotherapy: Moderately effective but inferior to other antihypertensives for CVD outcomes; associated with increased stroke risk compared to CCBs (RR 1.24) and RAS inhibitors (RR 1.30) 6
• ACE inhibitors: More effective than hydrochlorothiazide in reducing systolic and diastolic BP, and at least as effective as beta-blockers for diastolic BP reduction 5
• Combination therapy: Beta-blockers combined with thiazide diuretics show improved outcomes and are as effective as ACE inhibitors or calcium antagonists for total mortality, strokes, and MI 4

Implementation Strategy

If no compelling comorbidities exist:

• ACE inhibitors (lisinopril) are generally preferred over beta-blockers as first-line monotherapy given superior CVD outcomes 6
• Start lisinopril at low doses and titrate; onset of action within 1 hour, peak effect at 6 hours 2

If compelling cardiac indications exist (post-MI, stable CAD, angina):

• Metoprolol succinate is specifically indicated as GDMT 3
• Use lowest effective dose, consider three-times-daily dosing in bronchospastic disease to avoid higher plasma levels 1

Follow-up monitoring:

• Monthly visits for drug titration until BP controlled 3
• For lisinopril: Check electrolytes and renal function 1-2 weeks after initiation 7
• For metoprolol: Monitor heart rate and rhythm, assess for bradycardia 1