What is the best management approach for an elderly female patient with a history of hypertension, migraines, and vertigo, presenting with substernal chest pain, shortness of breath, and nausea, with evidence of moderate concentric left ventricular hypertrophy, mild-moderate mitral regurgitation, and mild aortic stenosis, but no obstructive coronary artery disease?

Management of Elderly Female with Chest Pain, LVH, and No Obstructive CAD

This patient's symptoms are most likely non-cardiac in origin given the comprehensive negative ischemic evaluation, and management should focus on aggressive blood pressure control to address the moderate concentric LVH from uncontrolled hypertension, while considering anxiety management given the significant caregiver stress.

Diagnostic Clarification

The clinical picture strongly suggests hypertensive heart disease rather than primary cardiac ischemia or hypertrophic cardiomyopathy:

• Negative ischemic evaluation with normal troponins initially, coronary CT showing zero calcium score, and no obstructive coronary disease definitively excludes significant epicardial coronary stenosis 1
• Moderate concentric LVH with LVEF 51% in the context of documented uncontrolled hypertension (systolic BP reaching hypertensive crisis levels) is consistent with hypertensive cardiomyopathy 1, 2
• The absence of severe LVH (wall thickness not mentioned as >15-20mm), normal ECG patterns, and history of hypertension all favor hypertensive etiology over hypertrophic cardiomyopathy 1
• The mildly elevated troponin (peaked at a low level) during one ED visit likely represents demand ischemia from severe hypertension rather than acute coronary syndrome 1

Primary Management Strategy: Aggressive Blood Pressure Control

Target BP <130/80 mmHg is essential to prevent progression to heart failure and reduce LVH 1, 2:

First-Line Pharmacological Approach

• ACE inhibitors or ARBs are the cornerstone of therapy for hypertensive cardiomyopathy with LVH, as they reduce ventricular remodeling and improve outcomes 2
• Beta-blockers should be added to target resting heart rate 50-60 bpm, with carvedilol, metoprolol succinate, or bisoprolol preferred for their mortality benefits 2
• Thiazide or thiazide-like diuretics should be included as first-choice agents for BP control and heart failure prevention 2

Critical Medication Considerations in This Elderly Patient

Avoid medications that worsen orthostatic hypotension, which is common in elderly patients and likely contributed to her intolerance of multiple agents 1:

• The patient's reported lightheadedness, nausea, and inability to tolerate multiple medications suggests orthostatic hypotension - BP should be measured supine and standing to document this 1
• Alpha-blockers should be avoided as they increase heart failure risk and worsen orthostatic symptoms 2
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided due to negative inotropic effects that may worsen heart failure symptoms 2
• Slow titration is essential in elderly patients with variable BP to avoid hypotensive episodes 1

The Amlodipine Success

The patient's improvement on amlodipine (a dihydropyridine calcium channel blocker) is appropriate for vasospastic angina consideration, though her symptoms are more likely non-cardiac 1:

• Continue amlodipine at the dose she tolerates (5mg daily) since it provides BP control without causing her adverse symptoms 1
• Add an ACE inhibitor or ARB at low initial dose (e.g., lisinopril 2.5-5mg daily or losartan 25mg daily) with careful titration 2
• Consider adding a low-dose beta-blocker (e.g., metoprolol succinate 12.5-25mg daily) if BP remains uncontrolled and heart rate is appropriate 2

Addressing the Mild Valvular Disease

The mild-moderate mitral regurgitation and mild aortic stenosis do not require specific intervention at this stage:

• These findings are common in elderly patients with hypertension and LVH and do not explain her symptoms 1
• Serial echocardiography every 1-2 years is appropriate to monitor progression 3
• The small pleural effusion likely reflects volume overload from uncontrolled hypertension and should improve with BP control 1

Non-Cardiac Symptom Management

The exertional chest pain with normal coronary arteries and negative stress testing strongly suggests a non-cardiac etiology:

Anxiety and Stress Management

• Significant caregiver stress is explicitly documented and is a major contributor to her symptoms 1
• Referral to primary care for anxiety evaluation is appropriate, as recommended by the cardiologist 1
• Consider selective serotonin reuptake inhibitors (SSRIs) rather than tricyclic antidepressants, which can prolong QT interval in elderly patients 1
• Avoid multiple QT-prolonging medications simultaneously, particularly in elderly females with cardiovascular disease and electrolyte abnormalities 1

Musculoskeletal Considerations

• Chest wall pain from musculoskeletal causes is common in elderly patients and can mimic cardiac symptoms 1
• Physical therapy and non-steroidal anti-inflammatory drugs (if renal function permits) may provide relief 1

Lifestyle Modifications

Non-pharmacological interventions are essential and may reduce medication requirements 2, 4:

• Sodium restriction to <2g daily for both hypertension and LV dysfunction management 2
• Daily weight monitoring (already initiated) to detect fluid retention early 2
• Supervised exercise training with careful BP monitoring can reduce cardiac events, though competitive sports should be avoided 2
• Weight loss if obese, smoking cessation, and management of other cardiovascular risk factors 2, 4

Monitoring Strategy

Close follow-up is essential given medication intolerance history:

• BP monitoring including orthostatic measurements at each visit to guide therapy adjustments 1
• Electrolytes and renal function should be checked 1-2 weeks after starting ACE inhibitor/ARB or diuretic 2
• Repeat echocardiography in 6-12 months to assess for LVH regression with tight BP control, which would confirm hypertensive etiology 1, 2
• ECG monitoring for any new conduction abnormalities or arrhythmias 1

Critical Pitfalls to Avoid

• Do not pursue further invasive cardiac testing given comprehensive negative evaluation - this risks unnecessary procedures and reinforces cardiac anxiety 1
• Do not use multiple antihypertensive agents simultaneously without establishing tolerance to each individually in this elderly patient with prior intolerance 1
• Do not ignore orthostatic symptoms - measure standing BP and adjust medications accordingly to prevent falls 1
• Do not overlook the psychosocial component - caregiver burden is a significant stressor requiring non-pharmacological support 1
• Avoid drastic BP reductions - target gradual reduction over weeks to months to prevent organ hypoperfusion in elderly patients 1