What treatment changes are recommended for an elderly female patient with hypertension, currently compliant with telmisartan 80mg and a calcium channel blocker?

Treatment Recommendation for Elderly Female with BP 160/80 on Current Therapy

Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily or indapamide 1.25-2.5 mg daily) to the current regimen of telmisartan 80 mg and calcium channel blocker, targeting a blood pressure goal of <130/80 mmHg. 1, 2

Rationale for Treatment Intensification

This patient has Grade 2 hypertension (systolic BP ≥160 mmHg) despite being compliant with dual therapy, which mandates treatment intensification. 2 The current regimen of telmisartan 80 mg (maximum dose) plus a calcium channel blocker represents two of the three primary antihypertensive drug classes, but the patient remains 30 mmHg above the recommended systolic target. 1

Specific Drug Addition

The third agent should be a thiazide-like diuretic:

• Chlorthalidone 12.5-25 mg once daily is the preferred option based on its prolonged half-life and proven cardiovascular disease reduction in clinical trials. 1
• Indapamide 1.25-2.5 mg once daily is an acceptable alternative with similar efficacy. 1
• Hydrochlorothiazide 25-50 mg daily is less preferred but acceptable if the above are not available. 1

The combination of an ARB (telmisartan) + calcium channel blocker + thiazide diuretic represents the standard three-drug regimen for resistant hypertension and has complementary mechanisms of action. 1, 3

Blood Pressure Targets for This Elderly Patient

Target systolic BP: 130-139 mmHg (not lower than 130 mmHg given age ≥65 years). 1

• The 2024 ESC guidelines specifically recommend that elderly patients (≥65 years) should target systolic BP of 130-139 mmHg rather than the more aggressive 120-129 mmHg target used in younger adults. 1
• Diastolic BP should be targeted to <80 mmHg. 1
• The current BP of 160/80 mmHg requires at least a 20-30 mmHg systolic reduction. 2

Monitoring and Titration Strategy

Follow-up in 2-4 weeks after adding the diuretic: 2

• Start chlorthalidone at 12.5 mg daily and assess BP response, electrolytes (sodium, potassium), and renal function. 1
• If BP remains >130 mmHg systolic after 4 weeks, increase chlorthalidone to 25 mg daily. 1
• Monitor for hypokalemia, hyponatremia, and hyperuricemia, which are common with thiazide diuretics. 1
• Implement home BP monitoring to confirm office readings and assess 24-hour control. 2

Important Caveats and Pitfalls

Do NOT add an ACE inhibitor to the current telmisartan (ARB): 1, 2

• Combining two renin-angiotensin system blockers increases risk of hyperkalemia, syncope, and acute kidney injury without additional cardiovascular benefit. 2

Monitor for orthostatic hypotension: 1

• Elderly patients are at higher risk for symptomatic orthostasis, particularly when intensifying therapy. 1
• Check standing BP at follow-up visits. 1

Assess for frailty or limited life expectancy: 1

• If the patient has clinically significant frailty or predicted lifespan <3 years, a more lenient target of <140/90 mmHg may be more appropriate. 1
• However, the question states the patient is "compliant," suggesting functional independence. 1

Alternative if Diuretic Not Tolerated

If the patient develops intolerable side effects from the thiazide diuretic (e.g., severe hypokalemia, gout exacerbation): 1

• Consider adding spironolactone 25 mg daily (preferred fourth-line agent for resistant hypertension). 1
• Monitor potassium closely given concurrent ARB use. 1
• Alternatively, consider switching the calcium channel blocker to a higher dose if not already maximized. 1

Concurrent Lifestyle Modifications

Reinforce sodium restriction to <2,300 mg/day (ideally <1,500 mg/day): 2, 4

• Sodium reduction can provide an additional 5-6 mmHg systolic BP reduction. 4

Encourage DASH diet pattern and regular aerobic exercise (90-150 minutes/week): 2, 4

• These lifestyle modifications enhance the efficacy of pharmacologic therapy. 4