What is the step-by-step medication management for an older adult patient with diastolic dysfunction and a history of hypertension, diabetes, or coronary artery disease?

Step-by-Step Medication Management for Diastolic Dysfunction

In older adults with diastolic dysfunction and comorbid hypertension, diabetes, or coronary artery disease, initiate treatment by aggressively controlling blood pressure to <140/90 mmHg (or <130/80 mmHg if tolerated) using ACE inhibitors or ARBs as first-line agents, followed by beta-blockers for heart rate control, and add diuretics judiciously only when fluid overload is present. 1

Step 1: Blood Pressure Control (Primary Target)

Target BP: <140/90 mmHg in most older adults with diastolic dysfunction, or <130/80 mmHg if well-tolerated and the patient is in good general condition 2. Avoid lowering diastolic BP below 60 mmHg, particularly in patients with isolated systolic hypertension or coronary artery disease 2, 3.

First-Line Agent Selection:

• ACE Inhibitors (e.g., lisinopril) or ARBs (e.g., losartan) should be the initial pharmacologic choice 2, 1, 4, 5
  • These agents block the renin-angiotensin system and have demonstrated efficacy in improving diastolic function measures 6
  • Start lisinopril at 10 mg daily or losartan at 25-50 mg daily in older adults 4, 5
  • Monitor renal function and potassium levels after 1-2 weeks of initiation, with each dose increase, and at least yearly 2

When to Initiate Treatment:

• BP 130-139/80-89 mmHg: Begin lifestyle modifications; if targets not achieved after maximum 3 months, add ACE inhibitor or ARB 2
• BP ≥140/90 mmHg: Initiate drug therapy immediately alongside lifestyle modifications 2
• Stage 2 hypertension (BP >20/10 mmHg above target): Consider starting with two agents from different classes 2

Step 2: Heart Rate Control (Secondary Target)

Beta-blockers should be added to control tachycardia and optimize diastolic filling time 1, 7:

• Metoprolol succinate extended-release 25-50 mg daily is appropriate for older adults 8
• Target resting heart rate of 60-80 bpm to improve ventricular filling time 1
• Use with caution in patients with bronchospastic disease; beta-1 selective agents are preferred 8
• Critical caveat: Beta-blockers can mask hypoglycemia symptoms in diabetic patients—monitor glucose closely 8

Alternative Rate Control:

• Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) may be used if beta-blockers are contraindicated 2, 7
• These agents also reduce albumin excretion in short-term studies 2

Step 3: Volume Management (Only When Congestion Present)

Diuretics should be used judiciously and only when clinical evidence of fluid overload exists 1, 7:

• Thiazide diuretics for mild volume overload or as part of combination therapy for hypertension 2
• Monitor electrolytes after 1-2 weeks of initiation, with each dose increase, and at least yearly 2
• Critical pitfall: Excessive diuresis can reduce preload excessively, worsening cardiac output in diastolic dysfunction 1, 7
• Avoid aggressive volume depletion—these patients are preload-dependent 2

Step 4: Treat Underlying Ischemia

Coronary revascularization should be considered when symptomatic or demonstrable myocardial ischemia adversely affects diastolic function 2, 7:

• Evaluate for coronary artery disease if angina or ischemic symptoms present 1
• Medical management of ischemia with nitrates can lower elevated filling pressures 7

Step 5: Combination Therapy (Most Patients Require Multiple Agents)

Three or more drugs are frequently needed to achieve BP targets in older adults with diabetes and hypertension 2:

Recommended Combinations:

1. ACE inhibitor/ARB + Beta-blocker (addresses both BP and heart rate) 1
2. ACE inhibitor/ARB + Thiazide diuretic (if volume overload present) 2
3. ACE inhibitor/ARB + Beta-blocker + Thiazide (for resistant hypertension) 2

Avoid:

• Dihydropyridine calcium channel blockers as monotherapy in patients with heart failure risk—use only in addition to ACE inhibitors/ARBs and beta-blockers 2
• Positive inotropes (e.g., digoxin)—these may worsen diastolic dysfunction 1

Step 6: Monitoring and Titration

• Check BP at every visit, including orthostatic measurements to assess for autonomic neuropathy or excessive BP lowering 2
• Renal function and potassium monitoring is essential with ACE inhibitors/ARBs 2
• Electrolytes must be monitored with diuretic therapy 2
• Follow-up within 1 month if BP >160/100 mmHg; within 3 months if BP 140-160/90-100 mmHg 2

Critical Caveats for Older Adults

• Orthostatic hypotension risk: Always measure BP in sitting and standing positions 2, 3
• Avoid excessive diastolic BP lowering: Do not lower diastolic BP below 60 mmHg, especially with coronary disease 2, 3
• Start low, go slow: Initial doses should be lower in elderly patients, with gradual titration 2
• Polypharmacy concerns: Most patients require 2-3 agents; fixed-dose combinations improve adherence 2
• Diabetes management: Beta-blockers mask hypoglycemia; monitor glucose closely 8

What NOT to Do

• Do not use heart failure medications (e.g., aldosterone antagonists, high-dose diuretics) in asymptomatic diastolic dysfunction—no proven benefit 7
• Do not aggressively lower BP in frail elderly or those with significant orthostatic changes 2, 3
• Do not use beta-blockers alone without addressing BP control first 1