What is the best treatment approach for a 73-year-old patient with hypertension and elevated Low-Density Lipoprotein (LDL) levels of 3.5 mmol/L?

Treatment Approach for 73-Year-Old with Hypertension and LDL 3.5 mmol/L

Initiate moderate-to-high intensity statin therapy immediately, combined with optimization of blood pressure control using a RAAS blocker plus calcium channel blocker or thiazide diuretic. This 73-year-old patient requires dual cardiovascular risk reduction targeting both hypertension and elevated LDL cholesterol, as the combination of these risk factors substantially amplifies cardiovascular disease risk 1, 2.

Lipid Management Strategy

Primary Statin Therapy

• Start a moderate-to-high intensity statin (e.g., atorvastatin 20-40 mg or rosuvastatin 10-20 mg daily) as first-line therapy 1, 3.
• The LDL-C level of 3.5 mmol/L (135 mg/dL) is above optimal targets for a patient with hypertension, who should be considered at elevated cardiovascular risk 1.
• Recent evidence demonstrates that individuals aged 70-100 years with elevated LDL cholesterol have the highest absolute risk of myocardial infarction and atherosclerotic cardiovascular disease, with the lowest number needed to treat (NNT) to prevent one event 2.

Target LDL-C Goals

• Aim for LDL-C <2.6 mmol/L (100 mg/dL) as a minimum target, with consideration for <1.8 mmol/L (70 mg/dL) if additional high-risk features are present 1.
• Reassess LDL-C levels 4-12 weeks after initiating statin therapy 4.

Intensification if Needed

• If LDL-C remains >2.6 mmol/L on maximally tolerated statin, add ezetimibe 10 mg daily 1, 4.
• Ezetimibe should be taken at least 2 hours before or 4 hours after bile acid sequestrants if those are used 4.
• For very high-risk patients (established cardiovascular disease, diabetes with target organ damage), consider PCSK9 inhibitors if LDL-C remains elevated despite statin plus ezetimibe 1.

Blood Pressure Management Strategy

Initial Antihypertensive Approach

• Initiate combination therapy with a RAAS blocker (ACE inhibitor or ARB) plus either a calcium channel blocker or thiazide/thiazide-like diuretic 1, 5.
• This combination approach is superior to monotherapy for achieving blood pressure control in elderly hypertensives 1.

Blood Pressure Targets

• Target blood pressure <140/90 mmHg as a minimum, with consideration for <130/80 mmHg if tolerated without adverse effects 1.
• Systolic blood pressure should be the primary target in this age group, as it is the strongest predictor of cardiovascular events in elderly patients 1.

Monitoring Considerations

• Implement home blood pressure monitoring to assess treatment response and detect white coat hypertension 1.
• Consider 24-hour ambulatory blood pressure monitoring if office readings are discordant with clinical picture 1.
• Watch for orthostatic hypotension, particularly after meals and upon standing, as elderly patients are more susceptible 1.

Safety Monitoring

Statin-Related Monitoring

• Check baseline liver enzymes (ALT/AST) and repeat if clinically indicated, particularly if symptoms develop 4.
• Monitor for myopathy symptoms (muscle pain, tenderness, weakness) and check creatine kinase if suspected 4.
• Discontinue statin if ALT/AST elevations ≥3× upper limit of normal persist 4.

Thiazide-Related Monitoring (if used)

• Monitor serum electrolytes, particularly potassium, as elderly patients are at higher risk for hypokalemia 5.
• Ensure adequate hydration, especially important in elderly patients 5.
• The recommended starting dose of hydrochlorothiazide is 12.5 mg; doses >25 mg add minimal benefit but increase adverse effects 5.

Critical Pitfalls to Avoid

• Do not withhold statin therapy based on age alone—contemporary evidence shows elderly patients derive substantial benefit from LDL-C lowering, with the highest absolute risk reduction 2, 3.
• Avoid aggressive blood pressure lowering that causes symptomatic hypotension, particularly orthostatic symptoms that increase fall risk 1.
• Do not use beta-blockers or diuretics as first-line monotherapy for blood pressure control in this patient, as RAAS blockers are preferred 1.
• Monitor for drug interactions if adding ezetimibe to other medications, particularly bile acid sequestrants 4.

Lifestyle Modifications

• Implement dietary modifications including reduced sodium intake (<2.3 g/day), increased fruits/vegetables, and reduced saturated fat 1.
• Encourage regular physical activity appropriate for age and functional status 1.
• Achieve and maintain ideal body weight if overweight 1.
• Smoking cessation if applicable 1.