From the Guidelines
For a 72-year-old female patient with hypertension on Bystolic and an ACE inhibitor whose blood pressure remains elevated at 150/80, I recommend optimizing her current treatment regimen and considering the addition of a diuretic, specifically a thiazide-like diuretic, as the next step in management, as per the 2020 international society of hypertension global hypertension practice guidelines 1. To address the patient's elevated blood pressure, it's crucial to first exclude causes of pseudoresistance, such as poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy, as suggested by the guidelines 1. Given that the patient is already on two antihypertensive medications, the next step would be to optimize the current treatment regimen, including health behavior change and considering the addition of a diuretic, if not already on one, or optimizing the dose of the current diuretic, if applicable 1. The guidelines suggest using thiazide-like rather than thiazide diuretics and initiating loop diuretics for eGFR <30 ml/min/1.73m2 or clinical volume overload 1. Additionally, if the patient's serum potassium is <4.5 mmol/L and eGFR is >45 ml/min/1.73m2, considering the addition of a low dose of spironolactone as the 4th line agent could be beneficial, as per the guidelines 1. It's also essential to reinforce non-pharmacological interventions, including sodium restriction, regular physical activity, weight management if needed, and limiting alcohol consumption, to help achieve the target blood pressure of below 130/80 mmHg. Close monitoring of the patient's blood pressure, electrolytes, and renal function will be necessary after any changes to her medication regimen, with follow-up appointments as needed to assess efficacy and tolerability.
From the Research
Patient's Condition
The patient is a 72-year-old female with a history of hypertension, currently on Bystolic (nebivolol) and an ACE inhibitor, with elevated blood pressure at 150/80 mmHg.
Treatment Options
- The patient is already on nebivolol, a third-generation β-blocker with additional vasodilatory effects, which has been shown to be effective in controlling blood pressure 2.
- The use of ACE inhibitors, such as the one the patient is currently taking, has been compared to angiotensin receptor blockers (ARBs) in several studies, with no significant difference in efficacy found between the two 3, 4.
- However, ARBs have been found to have a slightly lower incidence of adverse events, such as dry cough, compared to ACE inhibitors 3, 4.
Management of Elevated Blood Pressure
- The management of elevated blood pressure in the acute care setting is not well-established, and current practice varies significantly 5.
- The American Heart Association has issued a scientific statement on the management of elevated blood pressure in the acute care setting, highlighting the need for further research and evidence-based guidelines 5.
Potential Next Steps
- Consider switching the patient from an ACE inhibitor to an ARB, given the similar efficacy and lower incidence of adverse events with ARBs 3, 4.
- Continue to monitor the patient's blood pressure and adjust treatment as needed to achieve optimal control.
- Consider adding or substituting other antihypertensive medications, such as a diuretic or a calcium channel blocker, to achieve better blood pressure control.