How to manage uncontrolled hypertension in an elderly patient with a complex medical history and multiple medications?

Management of Uncontrolled Hypertension in This Elderly Patient

This patient requires immediate optimization of their current antihypertensive regimen by increasing the losartan dose to 100 mg daily and adding a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily), as most patients require more than one medication to achieve blood pressure control, with thiazide diuretics being the first-choice add-on agent. 1

Immediate Medication Adjustments

Optimize Current ARB Therapy:

• The patient is currently on losartan + hydrochlorothiazide combination, but the BP readings of 162/88 and 152/91 indicate inadequate control 2
• Verify the current losartan dose and titrate to the maximum of 100 mg daily if not already at this level, as this is the FDA-approved maximum dose for hypertension 2
• Consider switching from hydrochlorothiazide to chlorthalidone 12.5-25 mg daily, as chlorthalidone has superior outcome evidence and longer duration of action 3

Critical Consideration for This Patient:

• The patient has atrial fibrillation on dabigatran and first-degree heart block on ECG, which makes beta-blocker intensification less desirable 1
• Flecainide is already providing some rate control, so avoid adding additional AV nodal blocking agents 1

Systematic Approach to Resistant Hypertension

Rule Out Pseudo-Resistance First:

• Confirm BP measurements are accurate using proper technique (appropriate cuff size, seated position, arm supported at heart level) 1
• Obtain standing BP measurements to assess for orthostatic hypotension, which is common in elderly patients and may limit aggressive BP lowering (check for ≥20 mmHg systolic or ≥10 mmHg diastolic drop) 1
• Assess medication adherence objectively, as poor compliance is a frequent cause of uncontrolled hypertension in up to 50% of cases 4, 5

Evaluate for Secondary Causes:

• Review the recent labs: check serum creatinine and eGFR (which reportedly improved), potassium, and sodium 6
• The patient has diabetes and obesity, both risk factors for resistant hypertension 1
• Ensure no NSAIDs or other BP-elevating medications are being used 6

Medication Intensification Algorithm

Current Regimen Analysis:

• Losartan + hydrochlorothiazide (ARB + thiazide diuretic) - appropriate first-line combination 1, 3
• Flecainide - antiarrhythmic, no significant BP effect
• Atorvastatin - appropriate for cardiovascular risk reduction 1
• Metformin - appropriate for diabetes management 1

Step 1: Add Calcium Channel Blocker

• Add amlodipine 5 mg daily, titrate to 10 mg daily after 2-4 weeks if BP remains elevated 3
• This creates the preferred three-drug combination: ARB + thiazide diuretic + calcium channel blocker 7, 3
• Amlodipine is particularly appropriate given the patient's diabetes and does not interact with flecainide 3

Step 2: If Still Uncontrolled After 3 Months

• Add spironolactone 12.5-25 mg daily as the fourth-line agent, which is highly effective in resistant hypertension 6, 7
• Critical monitoring required: Check potassium and creatinine within 3-5 days, then weekly for 4 weeks, then monthly due to hyperkalemia risk with ARB + spironolactone combination 6
• Alternative fourth-line agents if spironolactone contraindicated: doxazosin, clonidine, or amiloride 7

Special Considerations for Elderly Patients

Target Blood Pressure:

• Aim for <130/80 mmHg in this patient who is functionally independent 3
• However, accept <140/90 mmHg if lower targets cause adverse effects such as dizziness, falls, or worsening weakness 6
• The patient's recent dizziness and ED visit warrant a cautious titration approach 1

Orthostatic Hypotension Management:

• The patient's presenting complaint of dizziness and weakness raises concern for orthostatic hypotension 1
• Obtain lying and standing BP measurements at every visit 1
• If orthostatic hypotension is documented, adjust diuretic dosing and ensure adequate hydration 1
• Warn the patient about postural symptoms and advise slow position changes 1

Critical Monitoring Parameters

Short-Term (1-2 Weeks After Any Change):

• Recheck BP in office with proper technique 3
• Obtain standing BP to assess for orthostatic changes 1
• Check serum creatinine, potassium, and sodium 6
• Assess for symptoms of hypotension (dizziness, weakness, falls) 1

Long-Term (Every 3 Months):

• Monitor HbA1c to ensure diabetes remains controlled (target <7%) 1
• Reassess eGFR given the patient's diabetes and hypertension 6
• Evaluate medication adherence and address barriers 4, 5
• Consider home BP monitoring to detect white-coat effect 5

Common Pitfalls to Avoid

Do Not:

• Stage hypertension based on a single BP reading; confirm with multiple measurements over time 5
• Use immediate-release nifedipine for acute BP lowering 8
• Abruptly discontinue any antihypertensive without tapering, especially clonidine if ever added 6
• Combine ARB with spironolactone without intensive potassium monitoring in elderly patients 6
• Ignore orthostatic symptoms, as they predict increased mortality and falls in elderly patients 1

Do:

• Titrate medications systematically rather than adding multiple agents simultaneously 3
• Reassess the medication regimen if eGFR declines below 30 mL/min, as thiazides lose effectiveness and loop diuretics become necessary 6
• Encourage lifestyle modifications including sodium restriction (<2 g/day), weight loss, and regular physical activity, which enhance medication efficacy 1, 3
• Consider referral for resistant hypertension evaluation if BP remains uncontrolled on 3+ medications including a diuretic at optimal doses with confirmed adherence 9