In an 85-year-old woman with hypertension, atrial fibrillation, chronic kidney disease, acute systolic congestive heart failure, prior cerebrovascular accident, dysphagia, recent pneumonia, thoracic vertebral fracture, and gait instability, who is currently taking metoprolol 50 mg daily and has allergies to hydralazine, lisinopril (ACE inhibitor) and amlodipine (dihydropyridine calcium‑channel blocker), what is the most appropriate antihypertensive medication to add for severe hypertension?

Optimal Antihypertensive Management for an 85-Year-Old with Multiple Comorbidities and Drug Allergies

Add an angiotensin receptor blocker (ARB) such as losartan or valsartan to the existing metoprolol regimen, as this patient requires combination therapy for severe hypertension and has compelling indications (atrial fibrillation, heart failure, CKD, prior stroke) that make ARBs the most appropriate choice despite ACE inhibitor allergy. 1

Rationale for ARB Selection

This 85-year-old patient presents with multiple compelling indications that make ARB therapy essential:

• Atrial fibrillation: ARBs may reduce AF recurrence and are specifically favored in this condition 1
• Acute systolic heart failure: ARBs are guideline-directed medical therapy for HFrEF, improving mortality and reducing hospitalizations 1, 2
• Chronic kidney disease: ARBs are recommended as first-line therapy for renal protection 1
• Prior cerebrovascular accident: ARBs are appropriate for secondary stroke prevention 1

The 2024 ESC Guidelines recommend combination therapy as first-line treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), with preferred combinations being a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine CCB or diuretic. 1 However, this patient's allergies eliminate both ACE inhibitors and dihydropyridine CCBs from consideration.

Specific Medication Recommendation

Start losartan 25 mg daily or valsartan 40 mg daily (lower starting doses appropriate for age ≥85 years), titrating upward as tolerated to target doses of losartan 50-100 mg daily or valsartan 160 mg twice daily. 1, 3

• Valsartan has demonstrated mortality benefit in post-MI patients with heart failure or LV dysfunction, with hazard ratios comparable to captopril 3
• Both agents provide cardiovascular mortality reduction and decrease heart failure hospitalizations 3, 2

Alternative Second-Line Options

If additional BP lowering is needed beyond metoprolol plus ARB:

Add a thiazide or thiazide-like diuretic (chlorthalidone 12.5-25 mg daily or indapamide 1.25-2.5 mg daily) as the next step, creating a three-drug combination of beta-blocker + ARB + diuretic. 1

• This combination is specifically recommended by 2024 ESC Guidelines when two-drug therapy is insufficient 1
• Thiazide diuretics are first-line agents with proven CVD event reduction 1
• Loop diuretics may be preferred if significant volume overload exists from acute heart failure 1

If three-drug therapy remains inadequate, consider adding spironolactone 12.5-25 mg daily (with careful monitoring of potassium and renal function given CKD). 1

Critical Considerations for This Patient

Age-Related Modifications

For patients aged ≥85 years, the 2024 ESC Guidelines recommend slower up-titration, lower dosing, and consideration of monotherapy initiation rather than combination therapy. 1 However, this patient's severe hypertension (170s-180s systolic) and multiple compelling indications justify combination therapy.

• Target BP should be 120-129 mmHg systolic if well tolerated, but a more lenient goal of <140/90 mmHg may be considered given age ≥85 years 1
• Monitor closely for symptomatic orthostatic hypotension, which is common in elderly patients and listed as an exception to aggressive BP lowering 1

Beta-Blocker Optimization

The current metoprolol 50 mg daily should be continued as it addresses multiple indications:

• Atrial fibrillation (rate control) 1
• Systolic heart failure (mortality benefit with metoprolol CR/XL) 1, 4
• Post-CVA (if ischemic etiology) 1

Beta-blockers are recommended to be combined with other major BP-lowering drug classes when there are compelling indications such as heart failure with reduced ejection fraction or heart rate control. 1

Medications to Avoid

Do not use:

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil): Contraindicated in systolic heart failure due to negative inotropic effects 1
• Alpha-blockers (doxazosin, prazosin): Associated with 2-fold increased risk of developing heart failure in ALLHAT trial 1
• Centrally acting agents (clonidine, moxonidine): Moxonidine associated with increased mortality in heart failure 1
• Direct vasodilators (minoxidil): Should be avoided due to renin-related salt and fluid retention 1
• Combining two RAS blockers: Not recommended (Class III recommendation) 1

Monitoring and Titration Strategy

Follow the patient monthly for medication titration until BP is controlled, with a goal of achieving target BP within 3 months. 1

• Measure BP at each visit, ideally with home BP monitoring to confirm office readings 1
• Monitor renal function and potassium within 1-2 weeks after initiating ARB, especially given pre-existing CKD 1
• Assess for orthostatic hypotension at each visit given age and multiple comorbidities 1
• Monitor heart rate if adjusting beta-blocker dose 1

Common Pitfalls to Avoid

Do not delay treatment initiation despite advanced age—confirmed hypertension (BP ≥140/90 mmHg) requires immediate pharmacological therapy regardless of CVD risk. 1

Do not use fixed-dose combinations initially in this patient given age ≥85 years and multiple comorbidities; individual dose titration allows better tolerance assessment. 1

Do not assume beta-blockers worsen peripheral circulation—they can be safely prescribed in patients with claudication as they do not worsen walking capacity or limb events. 1

Do not overlook medication adherence—dysphagia may complicate oral medication administration; consider liquid formulations or crushing tablets if appropriate for the specific medication. 1