What management approach is recommended for an elderly patient with labile hypertension, history of CABG and TAVR, well-controlled thyroid disease, and history of breast cancer, who is currently on Amlodipine?

Management of Labile Hypertension in an 87-Year-Old Post-TAVR Patient on Amlodipine

For this 87-year-old patient with labile hypertension on amlodipine monotherapy, add a low-dose ACE inhibitor (such as perindopril 2 mg daily) or ARB (such as losartan 50 mg daily) as the second agent, targeting a systolic blood pressure that is "as low as reasonably achievable" (ALARA principle) rather than aggressive targets, given her age >85 years and complex cardiac history. 1

Age-Specific Blood Pressure Management

• For patients ≥85 years old, the 2024 ESC guidelines recommend a more cautious approach: BP-lowering treatment should only be considered from ≥140/90 mmHg (office), with close monitoring of treatment tolerance. 1

• Target BP in this age group should follow the ALARA principle: If achieving a systolic BP of 120-129 mmHg is not tolerated, target a systolic BP level that is "as low as reasonably achievable" rather than forcing aggressive targets. 1

• Frailty assessment is critical: Screen for moderate-to-severe frailty using validated clinical tests, as the safety and efficacy of BP treatment is less certain in frail individuals. 1

Medication Selection for Elderly Post-TAVR Patients

• When initiating or intensifying BP-lowering treatment in patients aged ≥85 years, long-acting dihydropyridine CCBs (which she already takes) or RAS inhibitors should be considered first, followed by a low-dose diuretic if tolerated. 1

• Avoid beta-blockers unless compelling indications exist (such as heart failure or recent MI), and avoid alpha-blockers in this age group. 1

• For patients with aortic valve disease history (post-TAVR), RAS blockers (ACE inhibitors or ARBs) should be considered as part of BP-lowering treatment, making them an ideal second agent to add to her current amlodipine. 1

Specific Medication Recommendations

• Add an ACE inhibitor such as perindopril 2 mg daily OR an ARB such as losartan 50 mg daily to the existing amlodipine regimen. 2

• The combination of amlodipine with an ACE inhibitor/ARB provides complementary mechanisms: vasodilation from the CCB plus renin-angiotensin system blockade, and this combination is particularly beneficial for patients with coronary artery disease (post-CABG). 2

• Start at low doses given her age: The 2024 ESC guidelines specifically recommend starting with lower doses in patients ≥85 years. 1

Critical Safety Considerations for Labile Hypertension

• Before intensifying BP-lowering medication, test for orthostatic hypotension: Have the patient sit or lie for 5 minutes, then measure BP at 1 and/or 3 minutes after standing. 1

• Labile BP patterns require careful evaluation: If she has pre-treatment symptomatic orthostatic hypotension, this represents a special population where treatment should be approached even more cautiously. 1

• Pursue non-pharmacological approaches first for orthostatic hypotension if present, and switch medications that worsen orthostatic hypotension rather than simply de-intensifying therapy. 1

Monitoring and Follow-Up Protocol

• Reassess BP within 2-4 weeks after adding the second agent, checking both seated and standing pressures to monitor for orthostatic changes. 2

• Monitor for peripheral edema, which is more common with amlodipine and may actually be attenuated by adding an ACE inhibitor or ARB. 2

• Check serum potassium and creatinine 2-4 weeks after initiating ACE inhibitor/ARB therapy, particularly important given her age and history of cardiac disease. 2

• Once BP is controlled and stable, at least yearly follow-up for BP and other CVD risk factors should be considered. 1

Deprescribing Considerations

• If BP drops with progressing frailty, deprescription of BP-lowering medications may be considered, along with other drugs that can reduce BP such as sedatives. 1

• Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated—the key phrase being "if well tolerated." 1

Third-Line Options if Dual Therapy Fails

• If BP remains uncontrolled after optimizing the ACE inhibitor/ARB dose, add a low-dose thiazide-like diuretic (such as indapamide 2.5 mg daily or chlorthalidone 12.5 mg daily). 2

• The combination of ACE inhibitor/ARB + CCB + thiazide diuretic represents guideline-recommended triple therapy for uncontrolled hypertension. 2

• Monitor potassium closely if adding a diuretic to an ACE inhibitor/ARB, as the combination increases hyperkalemia risk. 2

Common Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB—this increases risk of hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit. 3, 2

• **Do not aggressively pursue standard BP targets (<130/80 mmHg) in this patient**—her age >85 years and complex cardiac history warrant the ALARA approach instead. 1

• Do not add a third drug class before optimizing doses of the current two-drug regimen—this violates guideline-recommended stepwise approaches. 2

• Do not assume treatment failure without first confirming medication adherence and ruling out secondary causes of hypertension, particularly given the labile nature of her BP. 2

Thyroid and Breast Cancer Considerations

• Well-controlled thyroid disease should not affect BP management strategy, but ensure thyroid function remains stable as thyroid dysfunction can contribute to BP variability. [@general medicine knowledge@]

• History of breast cancer does not contraindicate any of the recommended antihypertensive agents (ACE inhibitors, ARBs, CCBs, or thiazides). [@general medicine knowledge@]