What is the recommended treatment for an older adult with stage 2 hypertension?

Treatment of Stage 2 Hypertension in an Older Adult

This older woman with a blood pressure of 191/76 mmHg has Stage 2 hypertension and requires immediate initiation of combination antihypertensive therapy with two first-line agents from different classes, targeting a systolic blood pressure goal of <130 mmHg. 1

Immediate Management Approach

Medication Initiation

• Start combination therapy immediately with two agents: A thiazide-type diuretic (chlorthalidone 12.5-25 mg daily) plus either a calcium channel blocker (amlodipine 5 mg daily) or an ACE inhibitor/ARB (lisinopril 10 mg or losartan 50 mg daily). 1
• Stage 2 hypertension (BP ≥140/90 mmHg) mandates starting with two drugs rather than monotherapy, as this patient's systolic BP is >20 mmHg above target. 1
• Fixed-dose combination products are preferred when available, as they improve adherence and achieve faster BP control. 1

Blood Pressure Target

• The treatment goal is systolic BP <130 mmHg, regardless of age, based on strong evidence from SPRINT showing 25% reduction in cardiovascular events and 27% reduction in mortality with intensive treatment in older adults. 1
• All adults ≥65 years with hypertension have ≥10% 10-year ASCVD risk, automatically placing them in the high-risk category requiring aggressive treatment. 1
• The isolated systolic hypertension pattern (191/76 mmHg with wide pulse pressure) is the most common and challenging form in older adults but responds well to thiazide diuretics and calcium channel blockers. 2

Follow-Up Schedule

Initial Monitoring

• Reassess BP within 1 month after initiating therapy, as recommended for all Stage 2 hypertension. 1
• Monitor carefully for orthostatic hypotension at each visit by measuring BP in both sitting and standing positions, especially after dose adjustments. 1, 3, 4
• Check electrolytes and renal function within 2-4 weeks when using thiazide diuretics or ACE inhibitors/ARBs. 4

Titration Strategy

• If BP remains ≥130 mmHg systolic after 1 month, uptitrate existing medications to maximum tolerated doses before adding a third agent. 1
• Most patients require 2-3 medications to achieve BP control; sequential addition of agents is expected rather than a treatment failure. 5
• Continue monthly follow-up until BP goal is achieved, then extend to every 3-6 months once stable. 1

Critical Safety Considerations for Older Adults

Monitoring for Adverse Effects

• Orthostatic hypotension is the primary concern when initiating combination therapy in older adults, though SPRINT and HYVET demonstrated that intensive BP lowering is safe even in frail elderly patients living independently. 1
• Measure standing BP at every visit; a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing indicates orthostatic hypotension. 3, 4
• Watch for symptoms of hypoperfusion: dizziness, lightheadedness, falls, syncope, or confusion. 1

Cautious Titration Approach

• While combination therapy is indicated, start with lower doses in very elderly (≥80 years) or frail patients, then uptitrate based on tolerance. 1
• Avoid rapid dose escalation; allow 2-4 weeks between adjustments to assess full effect and tolerance. 1, 4
• Home BP monitoring should be implemented to detect patterns of hypotension between office visits. 3

Drug Selection Rationale

First-Line Agents

• Thiazide-type diuretics (especially chlorthalidone) provide optimal cardiovascular protection and are particularly effective for isolated systolic hypertension in older adults. 1, 5, 2
• Calcium channel blockers (amlodipine) are equally effective as monotherapy and particularly beneficial for wide pulse pressure hypertension. 6, 5, 2
• ACE inhibitors or ARBs are appropriate alternatives, especially if diabetes or chronic kidney disease is present. 7, 5

Agents to Avoid Initially

• Beta-blockers are less effective for stroke prevention in older adults and should not be first-line unless there is a compelling indication (heart failure, post-MI). 1
• Avoid simultaneous use of ACE inhibitor plus ARB plus renin inhibitor, as this combination is potentially harmful. 1

Lifestyle Modifications

Concurrent Non-Pharmacologic Therapy

• Dietary sodium restriction to <2 grams/day and increased potassium intake (unless contraindicated) enhance medication efficacy. 1, 5
• Weight loss of even 5-10 pounds can reduce systolic BP by 5-10 mmHg. 5
• Moderate physical activity (150 minutes/week) and limited alcohol consumption (<1 drink/day for women) provide additive BP reduction. 5
• These interventions are partially additive with medications and should be strongly emphasized even in treated patients. 5, 8

Common Pitfalls to Avoid

• Do not delay treatment waiting for lifestyle modifications alone; this patient's BP is too high for observation. 1
• Do not use monotherapy for Stage 2 hypertension; combination therapy achieves faster control and better outcomes. 1
• Do not undertitrate due to age alone; older adults derive substantial benefit from intensive BP lowering, including reduced mortality. 1
• Do not ignore the diastolic BP of 76 mmHg; while low-normal, it reflects arterial stiffness and wide pulse pressure, which is typical in older adults and does not contraindicate treatment. 1, 2
• Do not assume frailty precludes intensive treatment; both SPRINT and HYVET included frail older adults and demonstrated benefit. 1