In an elderly patient with heart failure (HF), would it be better to discontinue amlodipine (calcium channel blocker) or lisinopril (angiotensin-converting enzyme inhibitor, ACEi)?

Discontinue Amlodipine in Elderly Patients with Heart Failure

In an elderly patient with heart failure, amlodipine should be discontinued while lisinopril (the ACE inhibitor) must be continued and optimized, as ACE inhibitors are foundational mortality-reducing therapy in HF, whereas amlodipine increases heart failure hospitalizations and provides no survival benefit. 1

Evidence-Based Rationale

Why Lisinopril Must Be Continued

• ACE inhibitors like lisinopril reduce all-cause mortality and cardiovascular death in heart failure patients, with benefits demonstrated across all age groups including the elderly 1, 2
• Lisinopril is specifically effective and well-tolerated in elderly HF patients, improving exercise duration, left ventricular ejection fraction, and reducing hospitalizations 3, 4, 5
• Higher doses of lisinopril (32.5-35 mg daily) provide superior outcomes compared to low doses (2.5-5 mg daily), with 12% lower risk of death or hospitalization and 24% fewer HF hospitalizations, despite the common practice of underdosing 5, 6
• The ATLAS study demonstrated that elderly patients should be maintained on adequate ACE inhibitor doses rather than very low doses unless intolerance occurs 6

Why Amlodipine Should Be Discontinued

• Amlodipine significantly increases heart failure hospitalizations by 38% (RR 1.38; 95% CI 1.25-1.52) in the ALLHAT study, making it detrimental in established HF 1
• Dihydropyridine calcium channel blockers like amlodipine neither improve nor worsen survival in HF patients, providing no mortality benefit 1
• Amlodipine should only be used in HF for refractory hypertension after all other guideline-directed medical therapies have been optimized and failed, not as routine therapy 1
• The European Society of Cardiology guidelines position calcium channel blockers as last-line agents for blood pressure control in HF, to be added only after ACE inhibitors, beta-blockers, and diuretics 1

Clinical Implementation Algorithm

Step 1: Assess Current Lisinopril Dosing

• Verify the patient is on an adequate dose of lisinopril (target 20-35 mg daily based on tolerance) 5, 6
• If on low doses (<10 mg daily), plan gradual up-titration rather than discontinuation 2, 7
• Monitor supine and standing blood pressure, renal function (creatinine, BUN), and serum potassium within 10 days of any dose adjustment 2, 7

Step 2: Discontinue Amlodipine

• Taper amlodipine gradually over 1-2 weeks to avoid rebound hypertension if blood pressure is currently controlled
• Monitor blood pressure closely during the transition period 7

Step 3: Optimize Guideline-Directed Medical Therapy

• Ensure the patient is on a beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) for additional mortality benefit 1, 2
• Add or optimize aldosterone antagonist therapy (spironolactone or eplerenone) if not contraindicated by renal function or hyperkalemia 1
• Use loop diuretics (not thiazides) for volume management in elderly patients due to reduced glomerular filtration rate 1, 7

Step 4: Address Persistent Hypertension (If Present)

• If blood pressure remains elevated after optimizing ACE inhibitor and beta-blocker doses, consider carvedilol as the beta-blocker of choice due to its superior blood pressure-lowering effects via combined α1-β1-β2 blockade 1
• Only after maximizing guideline-directed therapies should amlodipine be reconsidered for refractory hypertension 1

Critical Monitoring Parameters

Within 10 Days of Medication Changes

• Recheck renal function (creatinine, eGFR) and electrolytes (potassium, sodium) as elderly patients are at higher risk for hyperkalemia with ACE inhibitors, especially when combined with aldosterone antagonists 1, 2
• Assess for orthostatic hypotension (supine and standing blood pressure) 1, 7
• Evaluate symptom improvement and signs of congestion (weight, edema, dyspnea) 7

Common Pitfalls to Avoid

• Do not discontinue the ACE inhibitor due to mild, transient increases in creatinine (up to 30% increase is acceptable and often stabilizes) 8
• Do not maintain elderly HF patients on very low doses of ACE inhibitors (2.5-5 mg lisinopril) when higher doses are tolerated, as this sacrifices significant clinical benefit 5, 6
• Do not use thiazide diuretics in elderly HF patients due to reduced effectiveness from decreased GFR; loop diuretics are preferred 1, 7
• Avoid NSAIDs and COX-2 inhibitors, as these commonly precipitate HF exacerbations and increase hyperkalemia risk 7

Special Considerations for the Elderly

• Start ACE inhibitor dose adjustments with smaller increments and longer titration periods compared to younger patients 1, 2
• Recognize that relief of symptoms may be a more important goal than life prolongation for some elderly patients, but this does not justify withholding proven mortality-reducing therapies 1, 7
• Screen for and manage common precipitants of HF decompensation including non-adherence, infections, anemia, atrial fibrillation, and renal dysfunction 7, 8