What is a suitable antihypertensive medication for an elderly patient over 80 years old with severe osteoporosis, hypertension, bronchial asthma, and coronary artery blockage, currently taking Dytor (Torsemide) and Myomarda (likely a Calcium Channel Blocker), with a systolic blood pressure over 140 mmHg?

Optimal Antihypertensive Medication for Your Elderly Relative

Add amlodipine 2.5 mg daily to her current regimen of Dytor (torsemide) and Myomarda (likely already a calcium channel blocker - verify this first, as it may be isosorbide mononitrate instead). If Myomarda is indeed a calcium channel blocker, consider adding a thiazide-like diuretic (chlorthalidone 12.5 mg or indapamide 1.25 mg) instead. 1

Why This Recommendation

First-Line Combination Therapy

• The 2024 ESC Guidelines establish that combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker (DHP-CCB) or thiazide-like diuretic is the preferred initial approach for most patients with confirmed hypertension (BP ≥140/90 mmHg). 2
• Your relative's systolic BP of 140+ mmHg meets the threshold for treatment intensification, particularly given her multiple cardiovascular risk factors including coronary artery disease. 2

Specific Advantages for This Patient

Calcium Channel Blockers (if not already on one):

• DHP-CCBs like amlodipine are particularly well-suited for elderly patients over 80 years because they do not cause bradycardia and are well-tolerated in this age group. 1
• Critical for her asthma: Unlike beta-blockers (which are contraindicated in bronchial asthma), calcium channel blockers actually improve bronchial permeability and can decrease pulmonary hypertension. 3
• For coronary artery disease, calcium channel blockers are appropriate and can help with angina management. 4
• Start with amlodipine 2.5 mg daily and titrate gradually to minimize vasodilatory side effects like ankle edema, which are more common in elderly patients. 1, 5

Thiazide-Like Diuretics (if already on a CCB):

• If Myomarda is confirmed to be a calcium channel blocker, adding a thiazide-like diuretic (chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg daily) represents the next logical step in triple therapy. 2, 6
• Thiazide-like diuretics are preferred over traditional thiazides due to longer duration of action and superior cardiovascular outcomes. 6
• These agents are safe in asthma and do not affect bronchial function. 3

Critical Medication Verification

You must first verify what "Myomarda" actually is:

• If it's a calcium channel blocker (like amlodipine or nifedipine), do NOT add another CCB - instead add a thiazide-like diuretic
• If it's isosorbide mononitrate (a nitrate for angina), then adding amlodipine 2.5 mg is appropriate
• Torsemide (Dytor) is a loop diuretic, not a thiazide, so it doesn't fulfill the role of first-line antihypertensive therapy 2

Blood Pressure Targets for This Patient

• Target BP: 140/90 mmHg as the initial goal, given her age >80 years, multiple comorbidities, and osteoporosis with fall risk. 7
• If well-tolerated without orthostatic hypotension or falls, BP can be cautiously lowered toward 130/80 mmHg, but this should be done gradually. 7
• The 2024 ESC Guidelines recommend targeting systolic BP of 120-129 mmHg in most adults, but for patients >85 years or with frailty, a more conservative approach is warranted. 2, 7

Specific Monitoring Requirements

Within 2-4 Weeks:

• Recheck BP to assess response to medication adjustment. 1
• Check orthostatic BP (sitting and standing) to screen for orthostatic hypotension, which increases fall risk in elderly patients with osteoporosis. 1

Within 1-2 Weeks (if adding thiazide-like diuretic):

• Monitor electrolytes (potassium, sodium) and renal function, as elderly patients are more susceptible to electrolyte disturbances. 6

Within 3 Months:

• Target BP control should be achieved within this timeframe. 1, 6

Medications to AVOID in This Patient

Beta-blockers are absolutely contraindicated due to her bronchial asthma - they can precipitate severe bronchospasm. 4

Treatment Algorithm

1. Verify current medications: Confirm what Myomarda actually is
2. If Myomarda is NOT a CCB: Add amlodipine 2.5 mg daily 1
   • Reassess in 2-4 weeks
   • If BP remains >140/90 mmHg, increase to amlodipine 5 mg daily 1
   • If still uncontrolled, add thiazide-like diuretic 2
3. If Myomarda IS a CCB: Add chlorthalidone 12.5 mg or indapamide 1.25 mg daily 6
   • Monitor electrolytes in 1-2 weeks 6
   • Reassess BP in 4-6 weeks 6
   • If uncontrolled, increase thiazide dose or consider adding an ARB 2

Additional Considerations for Osteoporosis

• Thiazide and thiazide-like diuretics may provide a secondary benefit by reducing urinary calcium excretion, potentially helping with osteoporosis management. 6
• Monitor for falls risk given severe osteoporosis - avoid aggressive BP lowering that could cause dizziness or orthostatic hypotension. 7

Lifelong Treatment

• Maintain BP-lowering treatment lifelong, even beyond age 85, if well tolerated - discontinuation increases cardiovascular risk. 2
• Use single-pill combinations when possible to improve adherence in elderly patients. 2