What is the next step in managing an elderly female patient with a history of chest pain and hypertension, who presents with hypercalcemia (elevated blood pressure) of 181/105 and EKG results showing sinus rhythm with minimal ST depression and ST deviation, following an ER visit?

Management of Elderly Female with Chest Pain, Uncontrolled Hypertension, and ECG Changes Following ER Visit

The next step is to optimize her antihypertensive regimen immediately while simultaneously completing risk stratification for acute coronary syndrome (ACS), as her presentation with chest pain, severe hypertension (181/105 mmHg), and ST-segment changes indicates both uncontrolled cardiovascular risk and possible ongoing ischemia. 1, 2

Immediate Assessment Priorities

Verify Medication Adherence First

• Non-compliance is the single most common cause of uncontrolled hypertension in patients on multiple medications 1
• Review her current antihypertensive regimen and assess whether she is actually taking medications as prescribed 1
• Ask specifically about barriers to adherence (cost, side effects, complexity of regimen) 1

Rule Out Ongoing ACS

• Elderly women with chest pain and hypertension are systematically underdiagnosed for ACS because their symptoms are misclassified as noncardiac 2
• Obtain serial cardiac troponins if not already done in the ER, as elderly patients frequently have silent or atypical myocardial infarction 2, 3
• The minimal ST depression and ST deviation on her ECG are concerning for NSTEMI/unstable angina, particularly in the context of severe hypertension which increases myocardial oxygen demand 4
• Do not assume symptoms are noncardiac based on "atypical" presentation—what is considered "atypical" is based on male symptom patterns 2

Assess for Acute Target Organ Damage

• Measure orthostatic blood pressures (supine and standing after 1 and 3 minutes) to identify orthostatic hypotension, which occurs in 7% of patients over 70 and carries 64% increased mortality 4, 3
• Examine for signs of acute heart failure: elevated jugular venous pressure, pulmonary rales, S3 gallop, and lower extremity edema, as 75% of patients hospitalized with heart failure had hypertension with systolic BP ≥140 mmHg 3
• Check for neurological deficits suggesting stroke or hypertensive encephalopathy 4
• This patient does NOT require emergency department transfer unless acute target organ damage is present, as elevated BP without acute complications does not constitute a hypertensive emergency requiring IV therapy 1

Hypertension Management Algorithm

Step 1: Optimize Diuretic Therapy (Highest Priority)

• Switch from any loop diuretic (furosemide) to chlorthalidone 12.5-25 mg once daily, as it has longer duration of action and superior efficacy 1
• If already on hydrochlorothiazide, consider switching to chlorthalidone for better 24-hour BP control 1
• This is the single most important intervention for uncontrolled hypertension in elderly patients 1

Step 2: Add or Optimize Calcium Channel Blocker

• Add amlodipine 5-10 mg once daily if BP remains uncontrolled after optimizing diuretic therapy 1
• Calcium channel blockers are particularly effective in elderly patients and are preferred in those with isolated systolic hypertension 4

Step 3: Consider Fourth-Line Agent

• Add spironolactone 25 mg once daily if BP remains uncontrolled despite optimized triple therapy 1
• Monitor potassium and renal function closely when adding spironolactone 1

Step 4: Confirm True Hypertension

• Arrange home blood pressure monitoring or 24-hour ambulatory monitoring to rule out white coat effect 1
• This is particularly important in elderly patients who may have exaggerated BP responses in clinical settings 1

Blood Pressure Targets

• Target BP <140/90 mmHg, ideally <130/80 mmHg if well tolerated 4, 1
• Avoid overly aggressive diastolic BP reduction below 60 mmHg in patients with coronary artery disease, as this may increase coronary events due to reduced coronary perfusion pressure 1
• Reassess BP within 2-4 weeks after any medication adjustment 1

Critical Pitfalls to Avoid

Do Not Rely on Nitroglycerin Response

• Nitroglycerin response is NOT diagnostic for cardiac ischemia, as esophageal spasm and GERD also respond to nitroglycerin 2
• Her symptom relief with nitroglycerin does not rule out or confirm ACS 2

Do Not Assume Absence of Symptoms Means Stability

• Elderly patients frequently present without typical symptoms even during acute cardiac events, with older adults with acute MI often lacking chest pain 3
• The absence of current symptoms does not exclude ongoing ischemia or recent infarction 3
• Dyspnea frequently substitutes for angina in older patients with coronary ischemia 3

Do Not Ignore Accompanying Symptoms

• Ask specifically about jaw/neck pain, back pain, epigastric symptoms, palpitations, nausea, diaphoresis, fatigue, and shortness of breath—these are more common in elderly women with ACS than classic chest pain 2

Additional Workup

Cardiac Risk Stratification

• Calculate GRACE score if troponins are elevated to assess ischemic risk 4
• Consider stress testing or coronary CT angiography once acute ischemia is excluded and BP is better controlled 4
• Women with diabetes have higher prevalence of angina but paradoxically lower incidence of obstructive CAD on angiography 2

Assess for Secondary Hypertension Causes

• Check renal function (creatinine, eGFR) and electrolytes 4
• Consider screening for obstructive sleep apnea if obese 4
• Evaluate for medication-induced hypertension (NSAIDs, decongestants, steroids) 1

Evaluate for Frailty

• Screen for frailty using validated clinical tests, as frail patients' health priorities should guide BP treatment intensity 4
• Assess for orthostatic hypotension before intensifying BP medications 4

Monitoring Plan

• Recheck BP within 2-4 weeks after medication adjustment 1
• Monitor for orthostatic symptoms with each medication change 4
• Ensure at least yearly follow-up once BP is controlled and stable 4
• Continue cardiac risk factor modification: statin therapy, antiplatelet therapy if indicated, smoking cessation if applicable 4