When should an older adult on multiple antihypertensive agents who presents with dizziness, orthostatic hypotension (standing systolic <90 mmHg or a drop ≥20 mmHg systolic/≥10 mmHg diastolic), acute illness, pre‑operative status, stage 4‑5 chronic kidney disease, or decompensated heart failure hold their blood pressure medications?

When to Hold Blood Pressure Medications in Older Adults

Immediate Indications to Hold Antihypertensive Medications

Older adults on multiple antihypertensive agents should hold their blood pressure medications when presenting with symptomatic orthostatic hypotension (standing systolic <90 mmHg or a drop ≥20 mmHg systolic/≥10 mmHg diastolic), acute illness with volume depletion, or pre-operative status requiring hemodynamic stability. 1, 2

Orthostatic Hypotension

• Hold all antihypertensive medications immediately when standing systolic blood pressure falls below 90 mmHg or when there is a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic upon standing, especially if accompanied by dizziness, lightheadedness, or syncope. 1, 2

• Orthostatic hypotension occurs in 5–33% of elderly patients and is a major contributor to syncope and falls in this population. 1

• Drug-induced orthostatic hypotension is poorly tolerated and can lead to sustained loss of perfusion to vital organs, resulting in myocardial infarction or stroke. 2

• Priority for discontinuation: First remove alpha-1 blockers (e.g., doxazosin, prazosin), centrally acting agents (e.g., clonidine), and adrenergic blockers, as these have the highest risk of orthostatic hypotension. 2

• Second priority: Reduce or hold diuretics if volume depletion is suspected, then consider dose reduction of ACE inhibitors, ARBs, calcium channel blockers, and beta-blockers. 1, 3

Acute Illness with Volume Depletion

• Hold diuretics and consider holding ACE inhibitors/ARBs during acute illness with vomiting, diarrhea, poor oral intake, or fever, as these conditions predispose to volume depletion and acute kidney injury. 4

• Sudden loss of blood volume or excess diuresis may precipitate orthostatic hypotension in any hypertensive patient. 2

• Resume medications only after volume status is restored and orthostatic vital signs are stable. 1

Pre-Operative Status

• Hold ACE inhibitors and ARBs on the morning of surgery, as these agents increase the risk of intraoperative hypotension requiring vasopressor support. 5

• Hold diuretics on the morning of surgery to prevent volume depletion and hypotension during anesthesia induction. 2

• Continue beta-blockers in patients with coronary artery disease or heart failure to prevent perioperative cardiac events, but hold in patients without compelling indications. 5

• Calcium channel blockers can generally be continued perioperatively unless there are specific concerns about hemodynamic instability. 5

Stage 4–5 Chronic Kidney Disease

• Hold or reduce ACE inhibitors and ARBs when serum creatinine rises acutely (>30% increase from baseline) or when potassium exceeds 5.5 mEq/L, as these agents increase the risk of hyperkalemia and acute kidney injury in advanced CKD. 4

• Diligent monitoring of serum potassium and creatinine is essential in older adults with CKD on ACE inhibitors, ARBs, potassium-sparing diuretics, or beta-blockers. 4

• Hold potassium-sparing diuretics (spironolactone, amiloride, triamterene) immediately when potassium exceeds 5.0 mEq/L in patients with stage 4–5 CKD. 4

Decompensated Heart Failure

• Do not routinely hold ACE inhibitors, ARBs, or beta-blockers in decompensated heart failure unless systolic blood pressure is <90 mmHg or the patient is in cardiogenic shock. 5

• Temporarily hold or reduce diuretics only if there is evidence of over-diuresis (e.g., rising creatinine, hypotension, hypokalemia), but continue diuresis if volume overload persists. 5

• In acute decompensated heart failure with preserved blood pressure (systolic ≥100 mmHg), continue guideline-directed medical therapy including ACE inhibitors/ARBs and beta-blockers at reduced doses if needed. 5

Medications Most Likely to Cause Orthostatic Hypotension

• Highest risk: Alpha-1 blockers (doxazosin, prazosin, terazosin), centrally acting agents (clonidine, methyldopa), and adrenergic blockers. 2

• Moderate risk: Diuretics (especially loop diuretics and high-dose thiazides), ACE inhibitors, ARBs, and non-dihydropyridine calcium channel blockers (diltiazem, verapamil). 1, 2

• Lower risk: Dihydropyridine calcium channel blockers (amlodipine, nifedipine) and beta-blockers, though these can still contribute to orthostatic hypotension in frail elderly patients. 1

Monitoring and Reassessment

• Check orthostatic vital signs (blood pressure and heart rate after 5 minutes supine, then at 1 and 3 minutes after standing) before initiating or intensifying antihypertensive therapy in older adults. 6

• Whenever possible, discontinue antihypertensive drugs causing orthostatic hypotension, and reduce dosages of essential drugs. 1

• Resume antihypertensive medications gradually after the acute issue resolves, starting with the lowest effective doses and monitoring for recurrent orthostatic hypotension. 1, 3

Critical Pitfalls to Avoid

• Do not continue all antihypertensive medications unchanged when an older adult presents with symptomatic orthostatic hypotension, as this increases the risk of falls, syncope, and end-organ hypoperfusion. 1, 2

• Do not overlook easily missed medications that worsen orthostatic hypotension, including tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. 3

• Do not assume that uncontrolled supine hypertension requires aggressive treatment in patients with orthostatic hypotension; instead, use short-acting antihypertensives at bedtime to target supine hypertension without worsening upright hypotension. 3