What is the antihypertensive of choice for a 90-year-old patient with essential hypertension and severely elevated blood pressure (hypertensive crisis)?

From the Guidelines

For a 90-year-old with essential hypertension presenting with acute elevated blood pressure of 180/110 mmHg, labetalol is the anti-hypertensive of choice. According to the European Heart Journal study 1, labetalol is the preferred first-line treatment for various hypertensive emergencies, including acute ischemic stroke, hypertensive encephalopathy, and acute hemorrhagic stroke. In the context of acute elevated blood pressure, labetalol's ability to reduce blood pressure while maintaining cerebral blood flow makes it an ideal choice. The goal is to lower blood pressure by 20-25% in the first few hours, and labetalol can be titrated to achieve this target.

Some key points to consider when using labetalol in this scenario:

• Labetalol can be used immediately to lower blood pressure in acute hypertensive emergencies 1
• The target blood pressure reduction is 20-25% in the first few hours, which can be achieved with labetalol 1
• Labetalol is preferred over nitroprusside in patients with hypertensive encephalopathy as it does not increase intracranial pressure and leaves cerebral blood flow relatively intact 1
• Alternative options like nitroprusside, nicardipine, and urapidil can be considered if labetalol is not available or contraindicated 1

It's essential to monitor blood pressure closely after initiating therapy and adjust the dose as needed to avoid excessive blood pressure reduction. The target blood pressure for patients over 80 years old is typically less aggressive, aiming for <150/90 mmHg rather than <130/80 mmHg recommended for younger patients, to balance cardiovascular protection with the risks of orthostatic hypotension and falls.

From the Research

Treatment Options for Essential Hypertension

The treatment of essential hypertension in a 90-year-old patient with an acute elevated blood pressure of 180/110 requires careful consideration of the available evidence.

• The first-line treatment for hypertension in adults without diabetes or cardiovascular or renal disease is usually a thiazide diuretic, such as chlortalidone or hydrochlorothiazide 2.
• Calcium channel blockers, such as amlodipine, are also effective in lowering blood pressure and reducing cardiovascular morbidity and mortality in hypertensive patients 3.
• ACE inhibitors, such as lisinopril, are also effective in reducing blood pressure and preventing cardiovascular events 4, 5.
• The combination of an ACE inhibitor and a calcium channel blocker, such as ramipril and amlodipine, may be a first-choice therapy for hypertension, as it has been shown to be effective in preventing myocardial infarction and total mortality 5.
• A study comparing amlodipine, lisinopril, and their combination found that the combination had a significant additional blood pressure lowering effect compared to either drug alone 6.

Considerations for the 90-Year-Old Patient

When considering treatment options for a 90-year-old patient, it is essential to take into account the patient's overall health status, including any comorbidities and potential interactions with other medications.

• Thiazide diuretics, such as chlortalidone, may be effective in this population, but may require careful monitoring of electrolyte levels and renal function 2.
• Calcium channel blockers, such as amlodipine, may be a good option for elderly patients, as they are generally well-tolerated and effective in lowering blood pressure 3, 4.
• ACE inhibitors, such as lisinopril, may also be effective in this population, but may require careful monitoring of renal function and potassium levels 4, 5.