What alternative treatment can be ordered for an elderly female patient with hypertension who is currently on atenolol (beta blocker) 25mg?

Optimal Antihypertensive Management for Elderly Female on Atenolol 25mg

Add a dihydropyridine calcium channel blocker (amlodipine 2.5-5 mg daily) as the most appropriate next step, as this provides superior blood pressure control in elderly patients compared to beta-blockers and avoids the adverse effects commonly seen with atenolol in this population. 1, 2

Why Change from Atenolol?

Beta-blockers like atenolol are relatively ineffective for blood pressure control in elderly patients and have higher rates of adverse effects compared to other antihypertensive classes. 3

• Beta-blockers reduced systolic blood pressure by only 5 mm Hg in elderly patients, compared to 15 mm Hg with calcium channel blockers and 13 mm Hg with diuretics. 3
• The LIFE trial demonstrated that losartan was more effective than atenolol in reducing cardiovascular events, particularly stroke, in elderly hypertensive patients. 4
• Beta-blockers were frequently contraindicated in elderly patients (15 of 74 patients in one study due to asthma/bronchospasm) and had more side effects with reduced well-being scores. 3

Recommended Treatment Algorithm

First-Line Addition: Calcium Channel Blocker

Start amlodipine 2.5 mg daily and titrate gradually over 4-week intervals. 1, 2

• Dihydropyridine calcium channel blockers do not cause bradycardia and are well-tolerated in elderly patients. 2
• They have the strongest evidence for reducing cardiovascular morbidity and mortality in elderly patients with isolated systolic hypertension. 4, 1
• Begin with the lowest dose (2.5 mg) to minimize vasodilatory side effects such as peripheral edema. 2

Alternative First-Line Addition: Thiazide Diuretic

If calcium channel blockers are not tolerated, add chlorthalidone 12.5 mg or indapamide 1.25 mg daily. 2

• Thiazide diuretics are the preferred first-line agent according to European Society of Cardiology guidelines, with strong evidence for reducing cardiovascular events in elderly patients. 1
• Monitor electrolytes carefully, especially potassium, in elderly patients. 2
• The combination of atenolol and chlorthalidone has demonstrated efficacy, though the effect is less than fully additive. 5

Second-Line Addition if Needed: ACE Inhibitor or ARB

If blood pressure remains uncontrolled on two drugs, add an ACE inhibitor (lisinopril 2.5-10 mg daily) or ARB (candesartan 4-8 mg daily). 1, 6

• ACE inhibitors are well-tolerated in elderly patients with low risk of orthostatic hypotension and no adverse metabolic effects. 7
• They provide additional cardiovascular and renal protection beyond blood pressure lowering. 7, 8
• The SCOPE trial showed significant stroke reduction (42% in isolated systolic hypertension) with candesartan in patients aged 70+ years. 4, 6
• Start with low doses and titrate gradually due to increased risk of adverse effects in elderly patients. 4, 6

Blood Pressure Targets and Monitoring

Target blood pressure is <140/90 mm Hg if tolerated. 1, 2, 6

• For patients ≥80 years old, <150/90 mm Hg is acceptable if <140/90 mm Hg cannot be achieved safely. 4
• Always measure blood pressure in both sitting and standing positions to assess for orthostatic hypotension, which is common in elderly patients. 4, 1, 6
• Recheck blood pressure within 4 weeks of any medication adjustment. 2
• Target control should be achieved within 3 months. 2

Critical Monitoring Requirements

• Check standing blood pressure at every visit to detect orthostatic hypotension (drop ≥20 mm Hg systolic or ≥10 mm Hg diastolic). 4, 1
• Monitor serum electrolytes (especially potassium) if using diuretics. 2
• Monitor renal function, as atenolol is renally excreted and accumulates when creatinine clearance falls below 35 mL/min/1.73m². 9
• Assess for peripheral edema if using calcium channel blockers. 2

Important Caveats

• Most elderly patients require two or more drugs to achieve blood pressure control, so combination therapy is expected rather than exceptional. 4, 1
• Never combine two renin-angiotensin system blockers (ACE inhibitor + ARB), as this increases adverse effects without significant benefit. 1
• If withdrawing atenolol is planned (due to inefficacy), it should be tapered gradually to avoid rebound hypertension, especially if the patient has coronary artery disease. 9
• Initial doses and titration should be more gradual in elderly patients due to greater risk of adverse effects. 4, 1