What is the most suitable initial antihypertensive medication for an elderly female patient with hypertension, possible Diabetes Mellitus (DM), and a history of transient slurred speech, given the options Lasix (furosemide), Lisinopril, Amlodipine, or Beta-blockers (BB)?

Recommended Antihypertensive for Elderly Female with TIA

Given this patient's presentation of a transient ischemic attack (TIA) with slurred speech that resolved, combined with untreated hypertension and possible diabetes, the best choice is B - Lisinopril (ACE inhibitor). 1, 2

Clinical Reasoning

Recognition of TIA as a Compelling Indication

• This patient experienced transient slurred speech lasting 30 minutes with negative CT, which represents a TIA—a critical cerebrovascular event requiring aggressive secondary stroke prevention 3
• TIA/stroke prevention is classified as a "compelling indication" that overrides standard first-line therapy recommendations 3
• ACE inhibitors like lisinopril provide specific cerebrovascular protection beyond blood pressure reduction alone 2

Why Lisinopril is Superior in This Context

For stroke prevention specifically:

• ACE inhibitors have demonstrated mortality reduction in hypertensive patients, preventing approximately 2-3 deaths and 2 strokes per 100 patients treated over 4-5 years 4
• Lisinopril provides renoprotective effects that are particularly important if diabetes is present, without adversely affecting glycemic control 2
• The drug preserves renal function in both normotensive and hypertensive diabetic patients with early nephropathy 2

For elderly patients:

• The American Heart Association recommends ACE inhibitors as appropriate first-line options for geriatric patients, with the advantage of once-daily dosing to improve adherence 1
• Starting with low-dose ACE inhibitor therapy is specifically recommended for non-Black elderly patients 1

Why NOT the Other Options

Lasix (furosemide) - Option A:

• Loop diuretics are NOT first-line agents for hypertension management 3, 5
• Reserved for volume overload states like heart failure, not uncomplicated hypertension
• Would be inappropriate as initial therapy in this clinical scenario

Amlodipine (calcium channel blocker) - Option C:

• While acceptable as first-line therapy generally, chlorthalidone was superior to amlodipine in preventing heart failure in direct comparison 4
• ACE inhibitors show greater renoprotective effects than calcium channel blockers despite similar antihypertensive efficacy 2
• Less compelling for secondary stroke prevention compared to ACE inhibitors

Beta-blockers - Option D:

• Not recommended as initial therapy in elderly patients due to higher risk of adverse effects 1
• Hydrochlorothiazide was more effective than the beta-blocker atenolol in reducing coronary events 4
• Can mask hypoglycemia symptoms if diabetes is present 6
• Associated with sexual dysfunction and may cause orthostatic hypotension in diabetics 6

Implementation Strategy

Initiation approach:

• Start lisinopril at low dose (5-10 mg daily) given elderly status 1
• Monitor blood pressure response over 3 months, targeting <140/90 mmHg (or <130/80 mmHg if diabetes confirmed) 1, 5
• Check renal function and potassium levels within 1-2 weeks of initiation 1

Critical monitoring:

• Assess for postural hypotension at each visit, as elderly patients are at increased risk 1
• Monitor for hyperkalemia, particularly if renal impairment develops 1
• Titrate gradually to full dose if BP target not achieved after 3 months 1

Important Caveats

• If blood pressure remains uncontrolled on maximum ACE inhibitor dose, add a thiazide-like diuretic (chlorthalidone or indapamide) as second agent 7, 5
• Ensure urgent neurology referral for complete TIA workup including carotid imaging and echocardiography (not addressed by antihypertensive choice alone)
• The presence of possible diabetes makes ACE inhibitor selection even more appropriate due to proven renoprotective benefits 2, 6