How to manage hypertension in an elderly patient with a blood pressure of 180/66, currently on furosemide (loop diuretic) 20mg, valsartan (angiotensin II receptor antagonist) 320mg, and amlodipine (calcium channel blocker) 5mg?

Management of Uncontrolled Hypertension in an Elderly Patient on Triple Therapy

Increase amlodipine from 5mg to 10mg daily as the next step, as this patient is already on a three-drug regimen (ARB + CCB + loop diuretic) but the calcium channel blocker is not yet at maximum dose. 1

Critical Clinical Context

This patient presents with isolated systolic hypertension (ISH) with a wide pulse pressure (114 mmHg), which is the predominant hypertension phenotype in elderly patients and carries significant cardiovascular risk. 1, 2 The systolic BP of 180 mmHg represents Grade 2 hypertension requiring immediate intensification of therapy. 1

Step-by-Step Treatment Algorithm

Step 1: Optimize Current Three-Drug Regimen

• Increase amlodipine to 10mg daily - The patient is currently on submaximal dosing of the CCB component, and dihydropyridine calcium channel blockers have proven efficacy in elderly patients with isolated systolic hypertension. 1

• Valsartan 320mg is already at maximum dose and should be continued. 1

• Consider switching furosemide 20mg to a thiazide-like diuretic (chlorthalidone 12.5-25mg or indapamide 1.25-2.5mg) - Loop diuretics are not the preferred diuretic class for hypertension management; thiazide-like diuretics have superior cardiovascular outcomes data and are specifically recommended by guidelines. 1

Step 2: If BP Remains Uncontrolled After 4-6 Weeks

• Add spironolactone 25mg daily as fourth-line therapy - This addresses potential aldosterone escape that occurs with long-term ARB therapy and provides a complementary mechanism of action. 1, 3

• Alternative fourth-line agents if spironolactone is contraindicated or not tolerated include amiloride, doxazosin, eplerenone, or clonidine. 1

Step 3: Verify Medication Adherence

• Check adherence before adding additional medications - Non-adherence is a common cause of apparent treatment resistance. 1

• Consider single-pill combinations to simplify the regimen and improve adherence. 1

Blood Pressure Targets for This Elderly Patient

Target BP: <140/90 mmHg, individualized based on frailty status. 1

• The 2020 International Society of Hypertension recommends a target of <140/90 mmHg for elderly patients, with individualization based on frailty. 1

• The 2024 ESC guidelines recommend targeting 120-129 mmHg systolic if well tolerated, but acknowledge that achieving "as low as reasonably achievable" (ALARA principle) is acceptable if the lower target is poorly tolerated. 1

• For patients ≥80 years, the 2017 ACC/AHA guidelines suggest 140-145 mmHg systolic is acceptable if tolerated, though the SPRINT and HYVET trials demonstrated safety and benefit of more intensive control even in this age group. 1

• Aim for at least a 20/10 mmHg reduction from baseline as an initial goal. 1

Critical Monitoring Parameters

• Check orthostatic blood pressures at every visit - Elderly patients have increased risk of orthostatic hypotension, though intensive BP control in trials did not increase fall risk in community-dwelling elderly. 1

• Monitor serum creatinine and potassium 1-2 weeks after any medication change, especially when adding spironolactone to an ARB. 4

• Assess for symptoms of hypoperfusion (dizziness, cognitive changes, fatigue). 1

• Avoid excessive lowering of diastolic BP below 70 mmHg - This can reduce coronary perfusion and increase CHD risk in elderly patients. 1

Important Caveats

• Do not combine two RAS blockers (ACE inhibitor + ARB) - This combination is specifically not recommended due to increased risk of hyperkalemia and acute kidney injury without additional benefit. 1

• Beta-blockers are not recommended as additional therapy unless there is a compelling indication (post-MI, heart failure with reduced ejection fraction, angina, or atrial fibrillation requiring rate control). 1

• Gradual dose titration is essential in elderly patients due to increased risk of adverse effects, though the target BP should ultimately be the same as younger patients if tolerated. 1, 2

• If the patient is frail, institutionalized, or has high comorbidity burden with limited life expectancy, a less aggressive target may be appropriate using clinical judgment. 1

Timeline for Achieving Control

• Achieve target BP within 3 months of treatment intensification. 1

• Recheck BP 2-4 weeks after each medication adjustment. 1

• Once controlled, monitor BP every 4-6 months with continued monitoring of renal function and electrolytes. 4