What is the best management approach for an elderly female patient with a history of hypertension, complaining of shortness of breath (SOB) on exertion and fatigue?

Management of Elderly Female with Hypertension, Exertional Dyspnea, and Fatigue

This patient requires urgent evaluation for heart failure with preserved ejection fraction (HFpEF), which is the most common cause of exertional dyspnea in elderly hypertensive patients, and immediate optimization of her blood pressure control with combination therapy targeting <130/80 mmHg.

Immediate Diagnostic Workup

Obtain transthoracic echocardiography (TTE) with tissue Doppler imaging as the first-line diagnostic test to assess for diastolic dysfunction, left ventricular hypertrophy, and ejection fraction 1. In elderly primary-care patients with shortness of breath on exertion, unrecognized heart failure is present in 16% of cases, with HFpEF (12%) being four times more common than HFrEF (3%) 1.

Essential Laboratory Tests

• NT-proBNP or BNP levels to support or exclude heart failure diagnosis (NT-proBNP >500 has 75% sensitivity and 83% specificity for HFrEF; combined with TTE, this improves diagnostic accuracy for HFpEF) 1
• Complete metabolic panel including serum creatinine, electrolytes, and estimated GFR to assess renal function before medication adjustments 1
• Complete blood count to exclude anemia as a contributing factor to fatigue 2
• Thyroid function tests (TSH) as hypothyroidism commonly presents with fatigue and can coexist with hypertension 2

Critical Echocardiographic Parameters to Assess

• Left atrial volume index and strain rate (significantly reduced in both HFrEF and HFpEF compared to non-HF patients) 1
• E/e' ratio (early mitral inflow velocity to early diastolic mitral annular velocity) to estimate left ventricular filling pressure 1
• Right ventricular systolic function using tissue Doppler imaging, as RV dysfunction has prognostic significance 1
• Longitudinal and circumferential strain using speckle tracking, as HFpEF patients demonstrate significantly impaired strain despite preserved ejection fraction 1

Blood Pressure Management Strategy

Initiate combination antihypertensive therapy immediately rather than monotherapy, as combination therapy provides more effective BP control and reduces cardiovascular events 1.

First-Line Combination Therapy

Start with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker (CCB) as initial therapy 1. Specifically:

• Losartan 50 mg once daily (can increase to 100 mg daily based on BP response) 3 OR another ARB
• Amlodipine 5 mg once daily (can increase to 10 mg daily if needed) 1, 2

Preferred as single-pill combination to improve adherence 1.

Target Blood Pressure

Aim for systolic BP 120-129 mmHg and diastolic BP <80 mmHg in this elderly patient, provided treatment is well tolerated 1. The 2024 ESC guidelines emphasize that treated systolic BP should target 120-129 mmHg in most adults to reduce cardiovascular risk 1.

Escalation Protocol if BP Not Controlled

If BP remains ≥140/90 mmHg after 2-4 weeks:

1. Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily or indapamide 1.25-2.5 mg daily) to create a three-drug combination, preferably as a single-pill combination 1, 2

2. If still uncontrolled, add spironolactone 25-50 mg daily as the fourth agent, which provides significant additional BP reduction in resistant hypertension 1

3. Monitor serum potassium and creatinine closely when combining RAS blockers with aldosterone antagonists, especially if renal function is impaired 1

Heart Failure Management (If Confirmed)

If HFpEF is Diagnosed

• Continue RAS blocker and diuretic therapy for BP control and symptom management 1
• Add loop diuretic (furosemide 20-40 mg daily) if volume overload is present, titrating to symptom relief 1, 4
• Consider beta-blocker if there is concurrent coronary artery disease, atrial fibrillation requiring rate control, or post-myocardial infarction 1

If HFrEF is Discovered (EF <40%)

• Beta-blocker is mandatory (metoprolol succinate 25-200 mg daily or carvedilol) for mortality benefit 1, 5
• ACE inhibitor or ARB titrated to maximum tolerated dose 1
• Aldosterone antagonist (spironolactone 25 mg daily) for additional mortality benefit 1
• Loop diuretic for volume management 1

Critical Monitoring Parameters

Within 2-4 Weeks of Initiating Therapy

• Recheck BP (both office and home measurements if possible) 1
• Assess for orthostatic hypotension by measuring BP after 5 minutes sitting/lying, then at 1 and 3 minutes after standing 1
• Repeat metabolic panel to check potassium and creatinine 1
• Evaluate symptom response (dyspnea, fatigue, exercise tolerance) 1

Ongoing Monitoring

• Once BP is controlled and stable, follow up at least yearly for BP and cardiovascular risk factors 1
• Serial echocardiography if heart failure is confirmed, to assess response to therapy 1

Important Clinical Caveats

Avoid These Common Pitfalls

• Do not use immediate-release nifedipine for BP control, as it should be avoided in hypertensive management 6
• Do not combine two RAS blockers (ACE inhibitor plus ARB), as this is not recommended and increases adverse events 1
• Do not start with monotherapy unless the patient is >85 years old, frail, or has symptomatic orthostatic hypotension 1
• Do not overlook medication non-adherence as a cause of uncontrolled hypertension, which is one of the most common causes of resistant hypertension 1

Screen for Secondary Causes if Resistant

If BP remains uncontrolled on three medications:

• Evaluate for obstructive sleep apnea (common cause of resistant hypertension in elderly patients) 1
• Consider renal artery stenosis, particularly if there is worsening renal function with RAS blocker initiation 1
• Check for primary aldosteronism if hypokalemia is present 1
• Assess medication adherence and consider supervised administration or simplification of regimen 1

Special Considerations for Elderly Patients

• Monitor for excessive diastolic BP lowering (avoid DBP <60 mmHg), as this increases fall risk and may worsen coronary perfusion 1, 7
• Use the ALARA principle ("as low as reasonably achievable") if the patient cannot tolerate target BP of 120-129 mmHg 1
• Screen for frailty using validated clinical tests, as moderate-to-severe frailty may warrant less aggressive BP targets (140/90 mmHg) 1, 7

Lifestyle Modifications (Essential Adjunct)

• Sodium restriction to <2 grams daily and potassium supplementation enhance medication efficacy 2
• Weight loss if overweight (even 5-10 kg reduction significantly lowers BP) 2
• Regular aerobic exercise (150 minutes weekly of moderate intensity) 2
• Limit alcohol consumption to <100 g/week of pure alcohol 1
• Mediterranean or DASH diet pattern 1, 2

The BP-lowering effects of lifestyle modifications are partially additive and enhance pharmacologic therapy efficacy 2.