What antihypertensive medication should a 62-year-old overweight man with significant atherosclerotic plaque burden, strong family history of cardiovascular disease, and baseline normotensive blood pressure be switched to after developing symptomatic hypotension on Triveram (fixed‑dose triple combination of an ACE inhibitor/ARB, calcium‑channel blocker, and low‑dose thiazide diuretic)?

Switching from Triveram to Monotherapy in Symptomatic Hypotension

This patient should be switched to monotherapy with a low-dose calcium channel blocker (amlodipine 2.5–5 mg daily) or discontinued from antihypertensive therapy entirely, given his baseline normotensive blood pressure (129/85 mmHg) and symptomatic hypotension on triple therapy. 1

Assessment of Current Situation

• The patient's baseline morning blood pressure of 129/85 mmHg without medication is below the treatment threshold for initiating pharmacologic therapy in most guidelines, which typically recommend starting antihypertensives at ≥140/90 mmHg 1
• Triveram contains a fixed triple combination (ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic at 20/5/5 mg doses), which represents aggressive therapy that is inappropriate for someone with baseline stage 1 or normal blood pressure 2, 1
• The patient's symptoms of dizziness and weakness after two weeks strongly suggest symptomatic hypotension from overtreatment 1

Recommended Treatment Strategy

Option 1: Complete Discontinuation (Preferred for Baseline BP 129/85 mmHg)

• Stop all antihypertensive medication and monitor home blood pressure for 2–4 weeks, as the patient's untreated BP of 129/85 mmHg does not meet the threshold for pharmacologic treatment in most adults 1
• Confirm true hypertension with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before restarting any medication 1
• The patient may have been started on Triveram based on isolated elevated office readings (white-coat hypertension) rather than sustained hypertension 1

Option 2: Switch to Monotherapy (If Cardiovascular Risk Justifies Treatment)

Given the patient's substantial atherosclerotic plaques, aggravated family history, and overweight status, if treatment is deemed necessary despite borderline BP, consider:

• Amlodipine 2.5–5 mg once daily as monotherapy, which provides cardiovascular protection in high-risk patients and is well-tolerated 1, 3
• Alternatively, a low-dose ACE inhibitor (lisinopril 5–10 mg daily) or ARB (losartan 25–50 mg daily) for patients with atherosclerotic disease, as these agents provide vascular protection beyond blood pressure lowering 1, 4, 5

Rationale for Avoiding Continued Triple Therapy

• Triple therapy is reserved for patients with uncontrolled hypertension (≥140/90 mmHg) despite dual therapy, not for initial treatment in someone with baseline normal-to-borderline BP 2, 1
• The 2007 ESH/ESC guidelines explicitly state that monotherapy should be the initial treatment for mild BP elevation with low or moderate cardiovascular risk, and combination therapy is reserved for grade 2–3 hypertension (≥160/100 mmHg) or very high cardiovascular risk 2
• Starting with triple therapy in this patient represents therapeutic overshoot that predictably caused symptomatic hypotension 2, 1

Monitoring After Medication Change

• Recheck blood pressure within 1–2 weeks after stopping Triveram to assess for rebound hypertension 1
• If monotherapy is initiated, reassess BP in 2–4 weeks with a target of <140/90 mmHg minimum, or <130/80 mmHg if well-tolerated in this high-risk patient 1
• Home BP monitoring should be implemented to guide ongoing management and avoid white-coat effect 1

Cardiovascular Risk Modification (Essential in This Patient)

• Sodium restriction to <2 g/day provides 5–10 mmHg systolic reduction and is particularly important given the atherosclerotic burden 1
• Weight loss (target BMI 20–25 kg/m²) can reduce BP by approximately 6/4.6 mmHg per 10 kg lost 1
• Regular aerobic exercise (≥30 minutes most days) lowers BP by approximately 4/3 mmHg 1
• DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy) reduces BP by 11.4/5.5 mmHg 1

Critical Pitfalls to Avoid

• Do not continue triple therapy in a patient with baseline normotensive BP who is experiencing symptomatic hypotension—this increases fall risk, syncope, and acute kidney injury without cardiovascular benefit 1
• Do not simply reduce the dose of Triveram to a lower fixed combination (e.g., 10/2.5/2.5 mg), as even this may be excessive for someone with baseline BP 129/85 mmHg 2, 1
• Do not assume the patient requires lifelong antihypertensive therapy without first confirming sustained hypertension off medication through home or ambulatory monitoring 1
• Do not restart combination therapy without first attempting monotherapy or lifestyle modification alone, as the patient's cardiovascular risk factors (atherosclerosis, family history, obesity) may be better addressed through aggressive lifestyle intervention and possibly statin therapy rather than aggressive BP lowering 1, 5

Special Consideration: Atherosclerotic Disease

• In patients with significant atherosclerotic plaque burden, excessively low blood pressure can reduce perfusion to stenotic vascular beds (coronary, cerebral, renal), potentially causing ischemic events 4, 5
• The presence of atherosclerosis is an indication for ACE inhibitor or ARB therapy if any antihypertensive is used, as these agents provide vascular protection, improve endothelial function, and retard atherosclerosis progression independent of BP lowering 4, 5
• However, this benefit must be balanced against the risk of symptomatic hypotension, which this patient is currently experiencing 1