What is the next step in managing an older adult patient with hypertension, a history of dizziness, and decreased ejection fraction on an echocardiogram, who is currently on lisinopril (Angiotensin-Converting Enzyme inhibitor) and hydrochlorothiazide (HCTZ) (diuretic)?

Management of Hypertension with Reduced Ejection Fraction

Add a beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) immediately to the current regimen of lisinopril and hydrochlorothiazide, as this is the critical missing component of guideline-directed medical therapy for heart failure with reduced ejection fraction. 1

Immediate Medication Optimization

The patient is already on an ACE inhibitor (lisinopril) and diuretic (HCTZ), but is missing the essential beta-blocker therapy that reduces mortality in heart failure with reduced ejection fraction:

• Initiate a beta-blocker proven to improve outcomes in HFrEF: carvedilol (starting 3.125 mg twice daily), metoprolol succinate (starting 12.5-25 mg once daily), bisoprolol (starting 1.25 mg once daily), or nebivolol 1
• Continue the ACE inhibitor (lisinopril) as it improves outcomes and lowers blood pressure in HFrEF 1
• Maintain the thiazide diuretic for blood pressure control and volume management, though consider switching from HCTZ to chlorthalidone for superior 24-hour blood pressure reduction if resistant hypertension develops 2

Add Aldosterone Receptor Antagonist

If the ejection fraction is <40% and the patient has NYHA class II-IV symptoms:

• Add spironolactone 12.5-25 mg once daily or eplerenone 25 mg once daily for additional mortality benefit 1
• Monitor serum potassium and creatinine closely (check 2-4 weeks after initiation) 1, 2
• Do NOT use if serum creatinine ≥2.5 mg/dL in men or ≥2.0 mg/dL in women, or if serum potassium ≥5.0 mEq/L 1

Blood Pressure Target Considerations

• Target blood pressure <140/90 mm Hg, with consideration for lowering to <130/80 mm Hg if tolerated 1
• In elderly patients with dizziness, lower blood pressure slowly and monitor for symptomatic hypotension, particularly diastolic blood pressure <60 mm Hg 1
• The dizziness may be related to excessive blood pressure lowering or orthostatic hypotension—measure blood pressure in both sitting and standing positions 1

Medications to Avoid

Critical contraindications in HFrEF with hypertension:

• Never use non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as they worsen heart failure outcomes 1
• Avoid clonidine, moxonidine, and hydralazine without a nitrate 1
• Use alpha-blockers (doxazosin) only if other agents at maximum tolerated doses fail to control blood pressure 1
• Use NSAIDs with extreme caution due to effects on blood pressure, volume status, and renal function 1

Monitoring and Titration Strategy

• Uptitrate beta-blocker to target doses (carvedilol 25 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily) over 8-12 weeks as tolerated 1
• Reassess blood pressure within 2-4 weeks after each medication adjustment 2
• Monitor for worsening heart failure symptoms, bradycardia, and hypotension during beta-blocker titration 1
• Check electrolytes and renal function 2-4 weeks after adding aldosterone antagonist 1, 2

Additional Considerations for Specific Populations

If the patient is African American with NYHA class III or IV HFrEF:

• Add hydralazine 37.5-75 mg three times daily plus isosorbide dinitrate 20-40 mg three times daily to the regimen of diuretic, ACE inhibitor, and beta-blocker for additional mortality benefit 1

Common Pitfalls to Avoid

• Do not delay beta-blocker initiation due to concerns about worsening heart failure—beta-blockers are essential for mortality reduction in HFrEF 1
• Do not abruptly discontinue any existing medications without careful consideration of rebound effects 2
• Do not use loop diuretics (like furosemide) as first-line therapy for blood pressure control unless creatinine clearance <30 mL/min, as thiazide-type diuretics are superior for blood pressure reduction 1, 2
• Start beta-blockers at low doses and titrate slowly to avoid symptomatic hypotension, particularly in elderly patients with dizziness 1