What is the best course of action for a patient with hypertension (HTN) on low-dose amlodipine (generic name: amlodipine) and ramipril (generic name: ramipril) who presents with elevated office blood pressure and a current chest infection?

Management of Elevated Office Blood Pressure in a Patient with Established Hypertension and Concurrent Chest Infection

Immediate Assessment and Confirmation

Before increasing medications, obtain out-of-office blood pressure readings to confirm true uncontrolled hypertension, as this single elevated office reading of 168/112 mmHg may represent white-coat effect or be temporarily elevated due to the acute chest infection. 1

• Arrange 24-hour ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) within 1 month for office BP readings of 160-179/100-109 mmHg to confirm the diagnosis before medication adjustment 1
• ABPM is preferred over HBPM as it has stronger prognostic evidence and can identify white-coat hypertension more reliably 1
• The diagnostic threshold for hypertension is ≥135/85 mmHg on ABPM (24-hour average) or HBPM, which is lower than the office threshold of ≥140/90 mmHg 1
• If ABPM/HBPM confirms average BP <135/85 mmHg, this represents white-coat hypertension and medication intensification may not be necessary 1

Impact of Acute Chest Infection on Blood Pressure

Do not increase blood pressure medications during an acute chest infection, as the infection itself can temporarily elevate BP through systemic inflammation, sympathetic activation, and the stress response. 2

• Acute infections commonly cause transient BP elevations that resolve with treatment of the underlying infection 2
• Wait until the chest infection has been treated and resolved (typically 1-2 weeks) before reassessing BP and making medication adjustments 1
• Premature medication intensification during acute illness may lead to hypotension once the infection resolves 2

When Out-of-Office Readings Confirm Uncontrolled Hypertension

If ABPM/HBPM confirms hypertension (≥135/85 mmHg average) after the chest infection has resolved, medication intensification is warranted:

Medication Adjustment Strategy

Increase ramipril from the current low dose to 5 mg once daily, as the usual maintenance dosage range is 2.5-20 mg per day, and patients on low doses have substantial room for titration. 3

• For patients with heart failure (which this patient has), ramipril can be dosed up to 5 mg twice daily (10 mg total daily dose) 3
• If BP remains uncontrolled after 2-4 weeks on increased ramipril, add or increase amlodipine dose, as the combination of ACE inhibitor + calcium channel blocker is a guideline-recommended first-line dual therapy 1
• The ramipril/amlodipine fixed-dose combination has superior adherence compared to ramipril alone (54% vs 30% one-year persistence) 4, 5

Target Blood Pressure

Aim for a target BP of <130/80 mmHg in this patient with hypertension and heart failure, but consider lowering even further to <120/80 mmHg if tolerated. 1

• In heart failure patients, successful trials achieved systolic BP in the range of 110-130 mmHg 1
• The COPERNICUS trial demonstrated benefits of beta-blockers in heart failure patients with mean BP of 123/76 mmHg, suggesting lower targets may be beneficial 1
• Avoid lowering diastolic BP below 60 mmHg, particularly in patients over 60 years or with diabetes, as this may compromise coronary perfusion 1

Monitoring and Follow-Up

• Reassess BP within 2-4 weeks after any medication change to evaluate response and guide further titration 1
• Continue monthly visits until target BP is achieved 1
• Encourage home BP monitoring twice daily during medication titration to assess treatment effectiveness 1
• Once BP is controlled, switch from 30-day to 90-day prescription refills to improve adherence 1

Common Pitfalls to Avoid

Do not add a second RAS blocker (such as an ARB) to the existing ramipril therapy, as dual RAS blockade increases risk of hyperkalemia, renal dysfunction, and hypotension without additional cardiovascular benefit 3

• The ONTARGET trial demonstrated that combining telmisartan with ramipril increased renal dysfunction without improving cardiovascular outcomes 3
• Avoid making medication changes based on a single elevated office reading without confirmation via out-of-office measurements 1
• Do not aggressively lower BP during acute illness, as this may cause hypotension once the acute stressor resolves 2
• Monitor for hyperkalemia when increasing ramipril dose, particularly in patients with renal impairment or heart failure 3
• Check renal function (creatinine, eGFR) and electrolytes within 1-2 weeks after increasing ACE inhibitor dose 3