What blood pressure medication is suitable for an older adult with a history of cardiovascular disease, experiencing dizziness and ankle swelling, who is currently taking [MEDICATION] 40 mg and [MEDICATION] 75 mg?

Blood Pressure Medication Selection for Patient with Dizziness and Ankle Swelling

Start with an ACE inhibitor (lisinopril 5-10 mg daily) or ARB (losartan 25-50 mg daily) as the first-line agent, avoiding calcium channel blockers entirely given the ankle swelling, which is a hallmark side effect of dihydropyridine calcium antagonists. 1, 2

Critical Context: Why Avoid Calcium Channel Blockers

• Ankle swelling is a dose-dependent vasodilatory side effect of calcium channel blockers, particularly dihydropyridines like amlodipine and nifedipine. 3
• The mechanism involves arteriolar dilation causing increased intracapillary pressure and fluid extravasation, which explains the patient's current ankle swelling. 3
• Studies demonstrate that 15-50% of patients on amlodipine develop peripheral edema, with higher rates at doses of 10 mg daily. 4, 5
• The dizziness likely represents orthostatic hypotension, which is exacerbated by aggressive blood pressure lowering in older adults, requiring careful medication selection and monitoring. 6

First-Line Recommendation: ACE Inhibitor or ARB

For this older cardiovascular patient, initiate lisinopril 5-10 mg once daily or losartan 25-50 mg once daily as monotherapy. 1, 2

• The 2017 ACC/AHA guidelines recommend starting with lower doses in older adults due to increased risk of orthostatic hypotension, with careful BP monitoring essential. 6
• ACE inhibitors and ARBs provide cardiovascular protection beyond blood pressure reduction alone, particularly important given the patient's cardiovascular disease history. 7
• These agents do NOT cause ankle swelling and may actually reduce edema if a calcium channel blocker is later needed for combination therapy. 3, 5

Monitoring Requirements in First 2-4 Weeks

• Check blood pressure in both sitting and standing positions to assess for orthostatic hypotension (drop >20 mmHg systolic or >10 mmHg diastolic), which could explain the dizziness. 6
• Monitor serum potassium and creatinine 1-2 weeks after initiating ACE inhibitor/ARB therapy, as hyperkalemia is the primary risk. 7
• Assess ankle swelling resolution, which should improve once any offending vasodilator is discontinued. 3

If Blood Pressure Remains Uncontrolled After 4-6 Weeks

Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) as the second agent rather than a calcium channel blocker. 1, 8

• Thiazide diuretics effectively lower blood pressure and reduce cardiovascular events in older adults without causing ankle swelling. 6, 8
• Chlorthalidone may be preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes. 8
• Monitor for hypokalemia, hyponatremia, and orthostatic hypotension, particularly in older adults. 6, 8

Only If Triple Therapy Needed: Calcium Channel Blocker Consideration

If blood pressure remains ≥140/90 mmHg on ACE inhibitor/ARB plus thiazide, then add amlodipine 2.5-5 mg daily (starting at lowest dose). 7, 1

• The combination of ACE inhibitor/ARB with calcium channel blocker significantly reduces vasodilatory edema compared to calcium channel blocker monotherapy. 3, 5
• ACE inhibitors attenuate ankle swelling from calcium channel blockers through mechanisms independent of blood pressure reduction. 5
• Start with 2.5 mg amlodipine in older adults and titrate slowly, monitoring closely for recurrent ankle swelling. 6

Critical Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB, as dual RAS blockade increases hyperkalemia and acute kidney injury without additional cardiovascular benefit. 7, 1
• Do not use loop diuretics (furosemide) for uncomplicated hypertension; these are reserved for volume overload states like heart failure. 7, 1
• Avoid immediate-release nifedipine due to risk of severe hypotension and heart failure exacerbation. 6
• Do not initiate two antihypertensive agents simultaneously in older adults with dizziness, as this increases risk of symptomatic hypotension and falls. 6

Target Blood Pressure and Timeline

• Target blood pressure <140/90 mmHg minimum, with consideration of <130/80 mmHg if tolerated without orthostatic symptoms or dizziness. 6, 7
• Reassess blood pressure monthly during titration, with goal of achieving target within 3 months of initiating therapy. 7
• In older adults with high comorbidity burden, clinical judgment favors more gradual titration over 3-6 months to minimize orthostatic hypotension risk. 6