How to manage hypotension in an elderly female patient with hypertension, taking atenolol 25mg and Benicar (olmesartan) 20mg, with blood pressure readings ranging from 120s/60s to 150/60s and diastolic readings in the 40s?

Management of Low Diastolic Blood Pressure in an Elderly Female on Atenolol and Olmesartan

Direct Recommendation

Reduce or discontinue atenolol 25mg first, as beta-blockers contribute significantly to low diastolic blood pressure and are not first-line agents for uncomplicated hypertension in elderly patients, while maintaining olmesartan 20mg to control the elevated systolic readings. 1

Understanding the Clinical Problem

Your patient presents with isolated diastolic hypotension (diastolic pressures in the 40s) alongside inadequately controlled systolic hypertension (readings up to 150 mmHg systolic). This pattern is common in elderly patients and represents a challenging clinical scenario. 1, 2

• The wide pulse pressure (difference between systolic and diastolic) reflects arterial stiffness typical of aging and indicates increased cardiovascular risk. 2, 3
• Diastolic blood pressure below 60 mmHg raises concerns about coronary perfusion, particularly during diastole when coronary blood flow occurs. 1
• However, the 2007 ESH/ESC guidelines noted that in the Syst-Eur trial, there was no evidence of harm down to a diastolic blood pressure of 55 mmHg, except in patients with pre-existing coronary heart disease. 1

Stepwise Treatment Algorithm

Step 1: Discontinue or Reduce Atenolol

• Beta-blockers like atenolol are not recommended as first-line therapy for uncomplicated hypertension in elderly patients and should only be used when there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control needs. 1
• Atenolol specifically contributes to both systolic and diastolic blood pressure reduction, and removing it will likely raise the diastolic pressure while having less impact on systolic control when combined with an ARB. 1
• Discontinue atenolol completely rather than tapering, as the 25mg dose is already low and abrupt cessation at this dose carries minimal risk in the absence of coronary disease or heart failure. 1

Step 2: Maintain Olmesartan at Current Dose

• Continue olmesartan 20mg as ARBs are recommended first-line agents for hypertension management and provide 24-hour blood pressure control. 1, 4
• The current olmesartan dose is moderate (maximum dose is 40mg), leaving room for uptitration if needed after atenolol discontinuation. 4

Step 3: Reassess Blood Pressure in 2-4 Weeks

• Monitor blood pressure both sitting and standing to assess for orthostatic hypotension, which is critical in elderly patients. 1, 5
• After atenolol discontinuation, expect diastolic pressure to rise by approximately 5-10 mmHg while systolic pressure may increase by 10-15 mmHg. 1

Step 4: If Systolic BP Remains Elevated (≥140 mmHg)

• Add a dihydropyridine calcium channel blocker (amlodipine 2.5-5mg daily) as the next step, which provides excellent systolic blood pressure reduction with minimal effect on diastolic pressure. 1, 5
• Start with amlodipine 2.5mg in elderly patients to minimize vasodilatory side effects such as peripheral edema and dizziness. 5
• The combination of ARB plus calcium channel blocker represents guideline-recommended dual therapy and is highly effective for isolated systolic hypertension. 1, 6

Step 5: Alternative if Amlodipine Not Tolerated

• Consider a thiazide-like diuretic (chlorthalidone 12.5mg or indapamide 1.25mg) as an alternative second agent. 1, 5
• Use the lowest effective dose (chlorthalidone 12.5mg) to minimize electrolyte disturbances, particularly hypokalemia and hypomagnesemia, which occur significantly more frequently at higher doses in elderly patients. 5
• Monitor serum potassium and creatinine 2-4 weeks after initiating diuretic therapy. 7

Blood Pressure Targets for This Patient

• Target systolic blood pressure of 130-139 mmHg for elderly patients aged ≥65 years, as recommended by the 2024 ESC guidelines. 1
• Accept diastolic blood pressure of 60-79 mmHg as appropriate, avoiding aggressive lowering below 60 mmHg given the uncertain benefit-risk ratio. 1
• For patients aged ≥85 years or those with symptomatic orthostatic hypotension, consider more lenient targets (systolic <140 mmHg). 1

Critical Pitfalls to Avoid

• Do not increase olmesartan dose while diastolic pressure remains in the 40s, as this will further lower diastolic pressure and potentially compromise coronary perfusion. 1
• Do not add a third antihypertensive agent before discontinuing atenolol, as this violates the principle of simplifying regimens when adverse effects occur. 1
• Do not assume the low diastolic pressure represents "overtreatment" requiring discontinuation of all medications, as the systolic pressure remains inadequately controlled and requires ongoing management. 1, 2
• Do not use non-dihydropyridine calcium channel blockers (diltiazem or verapamil) as they have negative chronotropic effects similar to beta-blockers and may worsen bradycardia. 7

Monitoring Parameters

• Check blood pressure in both sitting and standing positions at each visit to detect orthostatic hypotension, defined as a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing. 1, 5
• Assess for symptoms of hypoperfusion including dizziness, lightheadedness, syncope, falls, fatigue, or cognitive changes. 1, 5
• Monitor renal function and electrolytes if adding a diuretic, checking within 2-4 weeks of initiation. 5, 7
• Achieve target blood pressure within 3 months of treatment modification. 1, 8

Special Considerations for Elderly Patients

• Initiate dose changes gradually with lower starting doses and slower titration compared to younger patients, as elderly patients have increased susceptibility to adverse effects. 1, 9
• Simplify medication regimens using once-daily dosing and single-pill combinations when possible to improve adherence. 1, 5
• Continue lifelong treatment even beyond age 85 if well tolerated, as discontinuation increases cardiovascular risk. 1, 5
• Individualize based on frailty status, with more lenient targets for patients with moderate-to-severe frailty or limited life expectancy (<3 years). 1, 5