What is the appropriate management for a 65-year-old male patient with a history (Hx) of hypertension (HTN) on triple therapy (TTT), presenting with uncontrolled severe hypertension?

From the Guidelines

For a 65-year-old male with uncontrolled hypertension, I would first take a focused history including medication adherence, lifestyle factors, and symptoms of end-organ damage, and then assess for secondary causes of hypertension, medication side effects, and proper dosing, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Since he's on three antihypertensive medications with persistently elevated blood pressure (183/114 mmHg), I would consider the addition of low-dose spironolactone to existing treatment, as suggested by the 2024 ESC guidelines 1. The patient's physical examination should include:

• Cardiovascular assessment
• Fundoscopy
• Neurological examination to check for hypertensive damage Investigations should include:
• Basic metabolic panel
• Urinalysis
• ECG
• Possibly echocardiogram to assess for target organ damage

For hypertensive urgency treatment, I would use oral medications like amlodipine 10mg, labetalol 200-400mg, or captopril 25mg to gradually lower blood pressure by approximately 25% within the first few hours, then to 160/100 mmHg within 24-48 hours, as recommended by the 2020 International Society of Hypertension global hypertension practice guidelines 1. Rapid reduction should be avoided to prevent organ hypoperfusion.

For the non-adherent patient, I would explore his concerns about medications, educate him about hypertension complications, simplify his regimen if possible with combination pills, and involve him in decision-making, as suggested by the 2020 International Society of Hypertension global hypertension practice guidelines 1. When he mentions taking too many medications, I would explain the necessity of each medication, consider combination formulations to reduce pill burden, and discuss the risk-benefit ratio.

Dietary recommendations would include:

• The DASH diet (rich in fruits, vegetables, whole grains, lean proteins)
• Sodium restriction to less than 2300mg daily
• Limited alcohol consumption
• Increased potassium intake
• Regular physical activity I would emphasize that these lifestyle modifications complement but don't replace his medication regimen, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Captopril tablets should be taken one hour before meals. Dosage must be individualized. Hypertension - Initiation of therapy requires consideration of recent antihypertensive drug treatment, the extent of blood pressure elevation, salt restriction, and other clinical circumstances The initial dose of captopril tablets USP is 25 mg bid or tid. If satisfactory reduction of blood pressure has not been achieved after one or two weeks, the dose may be increased to 50 mg bid or tid. The dose of captopril in hypertension usually does not exceed 50 mg tid. A maximum daily dose of 450 mg captopril should not be exceeded.

To assess the patient now, we need to consider the patient's current medications, medical history, and the severity of the uncontrolled high blood pressure.

• Focused history should include questions about the patient's current medications, dosage, and any changes to the regimen.
• Examination and investigation may include checking for signs of target organ damage, such as cardiovascular or renal disease.
• To treat hypertensive urgency, the goal is to lower the blood pressure to a safe range, usually within a few hours.
  • The medication of choice may be an ACE inhibitor like captopril, a beta-blocker, or a calcium channel blocker.
  • The initial dose of captopril is 25 mg bid or tid, which can be increased to 50 mg bid or tid if necessary.
  • The goal is to reduce the blood pressure to a safe range, usually a diastolic blood pressure of less than 120 mmHg.
• If the patient is non-adherent to medication, we need to address the reasons for non-adherence and provide education on the importance of taking the medication as prescribed.
• For a patient taking multiple medications, we need to review the medication list and simplify the regimen if possible, to improve adherence.
• The recommended diet for a patient with hypertension is a low-sodium diet, rich in fruits, vegetables, and whole grains 2.

From the Research

Focused History

• The patient is a 65-year-old male with a history of hypertension (HTN) on triple therapy (TTT) who presents with uncontrolled high blood pressure over the last 4 days.
• The patient's vitals show a blood pressure of 183/114, a pulse of 75 bpm, and a respiratory rate of 20.
• A focused history should include questions about the patient's current medications, any changes to their medication regimen, and any potential factors contributing to their uncontrolled hypertension, such as diet, exercise, and stress levels 3.

Assessment and Examination

• The patient's medication regimen should be assessed to determine if any changes are needed.
• A physical examination should be performed to look for signs of target organ damage, such as retinal changes, cardiac abnormalities, or renal dysfunction.
• Laboratory tests, such as a complete blood count, basic metabolic panel, and urinalysis, may be ordered to evaluate for any underlying conditions that may be contributing to the patient's hypertension 4.

Treatment of Hypertensive Urgency

• Hypertensive urgency is defined as a blood pressure elevation without evidence of acute target organ damage.
• Treatment of hypertensive urgency typically involves oral medications, such as nifedipine, captopril, clonidine, labetalol, prazosin, or nimodipine, to gradually lower the blood pressure over a period of hours 3.
• The goal is to reduce the blood pressure to a safe level, typically < 160/100 mmHg, over a period of hours to avoid causing hypotension or other adverse effects 5.

Patient Non-Adherence

• If the patient is not taking their medication as prescribed, the reasons for non-adherence should be explored and addressed.
• The patient should be educated on the importance of taking their medication as prescribed and the potential consequences of uncontrolled hypertension.
• A plan should be developed to improve the patient's adherence to their medication regimen, such as simplifying the regimen, providing reminders, or offering support and encouragement 6.

Dietary Considerations

• A healthy diet is essential for managing hypertension, and the patient should be advised to follow a diet that is low in sodium, saturated fat, and cholesterol.
• The patient should be encouraged to increase their intake of fruits, vegetables, whole grains, and lean protein sources.
• The DASH (Dietary Approaches to Stop Hypertension) diet is a well-studied diet that has been shown to be effective in lowering blood pressure and should be recommended to the patient 7.

Medication Management

• The patient's medication regimen should be reviewed and optimized to ensure that they are taking the most effective medications for their hypertension.
• The patient should be monitored regularly to assess the effectiveness of their medication regimen and to make any necessary adjustments.
• The patient should be educated on the importance of taking their medication as prescribed and the potential consequences of uncontrolled hypertension 4.