What are the best hypertension (HTN) medications for an 85-year-old patient with atrial fibrillation (afib) and heart failure (HF)?

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Last updated: April 16, 2025 • View editorial policy

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From the Guidelines

For an 85-year-old with atrial fibrillation (AFib) and heart failure (HF), the optimal hypertension medications would be beta-blockers and ACE inhibitors/ARBs, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Beta-blockers like metoprolol succinate (starting at 25mg daily) or carvedilol (starting at 3.125mg twice daily) provide triple benefit by controlling blood pressure, reducing heart rate in AFib, and improving heart failure outcomes, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. ACE inhibitors such as lisinopril (starting at 2.5-5mg daily) or ARBs like losartan (starting at 25-50mg daily) are also excellent choices as they reduce blood pressure while providing cardioprotection and improving heart failure symptoms, as stated in the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1. Some key points to consider when treating this patient population include:

  • Dose adjustments should be made gradually, typically every 2-4 weeks, with careful monitoring of blood pressure, heart rate, renal function, and electrolytes.
  • In this elderly patient, starting at lower doses is crucial to avoid hypotension, dizziness, and falls.
  • Diuretics like furosemide may be added if fluid retention persists.
  • Calcium channel blockers of the dihydropyridine class (amlodipine) can be considered as add-on therapy, but non-dihydropyridines (diltiazem, verapamil) should be avoided as they can worsen heart failure.
  • It is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
  • Before starting or intensifying BP-lowering medication, it is recommended to test for orthostatic hypotension, by first having the patient sit or lie for 5 min and then measuring BP 1 and/or 3 min after standing, as recommended in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This medication approach addresses all three conditions simultaneously while minimizing polypharmacy in an elderly patient.

From the Research

Treatment Options for Hypertension in 85-year-old Patients with Atrial Fibrillation and Heart Failure

  • The treatment of hypertension in patients with atrial fibrillation and heart failure is crucial to reduce the risk of stroke, heart failure hospitalizations, and mortality 2, 3.
  • Beta-blockers, such as metoprolol succinate, are commonly used to treat heart failure and atrial fibrillation, and have been shown to reduce mortality and morbidity in these patients 2.
  • Other beta-blockers, such as carvedilol and bisoprolol, have also been used to treat heart failure, but their effectiveness compared to metoprolol succinate is still debated 4, 5.
  • A study comparing carvedilol and metoprolol succinate in patients with stable chronic heart failure found no conclusive association between all-cause mortality and treatment with either drug 4.
  • Another study found that among older adults with heart failure, the use of carvedilol, bisoprolol, or metoprolol tartrate was not significantly different in terms of all-cause mortality 5.

Considerations for Elderly Patients

  • Atrial fibrillation is a common clinical problem in elderly patients, and its prevalence increases with age 6.
  • Elderly patients with atrial fibrillation and heart failure require careful management, including rate control and anticoagulation therapy, to reduce the risk of stroke and heart failure hospitalizations 6.
  • New antiarrhythmic and anticoagulation medications, such as dronedarone and dabigatran, may be used in elderly patients, but more trials are needed to clarify their safety and long-term efficacy in this population 6.

Medication Options

  • Metoprolol succinate is a commonly used beta-blocker for the treatment of heart failure and atrial fibrillation, and has been shown to reduce mortality and morbidity in these patients 2.
  • Carvedilol and bisoprolol are also used to treat heart failure, but their effectiveness compared to metoprolol succinate is still debated 4, 5.
  • The choice of beta-blocker should be individualized based on the patient's specific clinical characteristics and comorbidities 2, 4, 5.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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