First-Line Antihypertensive for a 74-Year-Old Man with Hyperlipidemia and Hypothyroidism
Start with a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily or indapamide 1.25-2.5 mg daily) as first-line therapy for this elderly patient with hypertension and hyperlipidemia. 1, 2
Rationale for Thiazide-Like Diuretics in This Patient
Thiazide diuretics are specifically recommended as first-line therapy for elderly patients (>65 years) with hypertension, demonstrating superior efficacy in preventing cardiovascular events and stroke in this age group 1, 2
Chlorthalidone has the strongest evidence base, supported by three large comparative trials involving over 50,000 patients, showing superiority over ACE inhibitors in preventing stroke and over calcium channel blockers in preventing heart failure 2
Thiazide diuretics reduce all-cause mortality by 2-3 deaths per 100 patients treated over 4-5 years, one of only two drug classes (along with ACE inhibitors) proven to reduce overall mortality 2
The presence of hyperlipidemia is not a contraindication to thiazide therapy, and comprehensive cardiovascular risk reduction should include statin therapy given this patient's age and lipid disorder 3, 1
Alternative First-Line Options
If thiazide diuretics cannot be used, a dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) is the preferred alternative for patients over 55 years of age 3, 1, 4
ACE inhibitors or ARBs (such as lisinopril or losartan) are reasonable alternatives if diuretics and calcium channel blockers are contraindicated, though they are generally recommended for younger patients (<55 years) as initial monotherapy 3, 1, 5
Special Considerations for This Patient
Hypothyroidism Management
Ensure the patient's hypothyroidism is adequately treated with thyroxine replacement, as correction of hypothyroidism alone can substantially reduce both systolic and diastolic blood pressure, particularly in younger subjects 6
Hypothyroidism contributes to hypertension through increased peripheral resistance and is often accompanied by diastolic hypertension, making blood pressure control essential 7
Hyperlipidemia Considerations
While thiazide diuretics can provoke hyperglycemia, this does not reduce their efficacy in preventing cardiovascular events 2
Hypothyroidism itself causes hypercholesterolemia and increased LDL levels, which typically improve with thyroxine therapy 7
Add statin therapy for primary prevention given this patient's age (74 years), hypertension, and hyperlipidemia, as recommended for patients with 10-year coronary heart disease risk >30% 3
Implementation Strategy
Start with chlorthalidone 12.5 mg daily or indapamide 1.25 mg daily, using lower initial doses in elderly patients and titrating gradually 1, 2
Monitor electrolytes and renal function 1-2 weeks after initiation, checking for hypokalemia, hyperuricemia, and glucose intolerance 8, 9
Reassess blood pressure within 4-6 weeks, with a target of <140/90 mmHg (or <130/80 mmHg if tolerated without orthostatic hypotension) 9, 1
If blood pressure remains uncontrolled after 4-6 weeks, add a calcium channel blocker (amlodipine) or increase thiazide dose to 25 mg daily before considering triple therapy 8, 1
Critical Monitoring Parameters
Check for orthostatic hypotension at each visit, as elderly patients are at higher risk for falls and postural symptoms 1
Monitor potassium levels closely, particularly if combining with ACE inhibitors or ARBs later, as potassium >5.5 mmol/L requires dose reduction 9
Achieve target blood pressure control within 3 months of initiating therapy, not 6-12 months, to maximize cardiovascular risk reduction 9
Use once-daily dosing and consider single-pill combinations to improve adherence in this elderly patient 1