What is the appropriate next antihypertensive management for a 71‑year‑old man with stage‑2 hypertension (blood pressure 155/86 mm Hg) who is currently taking metoprolol 25 mg daily?

Appropriate Next Antihypertensive Management

Add a thiazide-like diuretic (chlorthalidone 12.5–25 mg daily or hydrochlorothiazide 25 mg daily) to the current metoprolol 25 mg regimen to achieve guideline-recommended dual therapy for this 71-year-old patient with stage 2 hypertension (155/86 mm Hg). 1

Blood Pressure Classification and Treatment Urgency

• This patient has stage 2 hypertension (systolic ≥140 mm Hg), which requires prompt pharmacologic intensification rather than lifestyle modification alone. 1
• The 2017 ACC/AHA guidelines establish that for adults ≥65 years, the vast majority (88% overall, 100% of those ≥75 years) have 10-year ASCVD risk ≥10%, making a target BP of <130/80 mm Hg appropriate if well tolerated, with a minimum acceptable goal of <140/90 mm Hg. 1
• The 2024 ESC guidelines recommend an initial target of <140/90 mm Hg for all patients, with a more intensive target of 120–129 mm Hg systolic if treatment is well tolerated. 1

Rationale for Adding a Thiazide Diuretic

• Beta-blockers like metoprolol are not recommended as first-line monotherapy for uncomplicated hypertension in older adults; they are less effective than diuretics and calcium channel blockers for stroke prevention and cardiovascular event reduction. 1
• Adding a thiazide diuretic to metoprolol creates a rational two-drug combination that targets complementary mechanisms: beta-blockade reduces cardiac output and renin release, while diuretics provide volume reduction. 1, 2
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action (24–72 hours vs 6–12 hours) and superior cardiovascular outcome data from the ALLHAT trial. 2, 3
• If chlorthalidone is unavailable, hydrochlorothiazide 25 mg daily is an acceptable alternative, though it remains inferior to chlorthalidone for 24-hour BP control. 2

Dosing and Titration Strategy

• Start chlorthalidone at 12.5–25 mg once daily in the morning (or hydrochlorothiazide 25 mg daily if chlorthalidone unavailable). 1, 3
• The FDA-approved dosing for chlorthalidone in hypertension begins at 25 mg daily, with increases to 50 mg or 100 mg if needed, though doses above 100 mg rarely increase effectiveness. 3
• Slower dose escalation is preferred in elderly patients to minimize adverse effects while maintaining BP control; research demonstrates that titrating every 6 weeks rather than every 2 weeks provides higher control rates (68% vs 62.3%) with fewer serious adverse events. 4
• Reassess BP within 2–4 weeks after adding the diuretic, with the goal of achieving target BP within 3 months of treatment modification. 1

Monitoring After Diuretic Addition

• Check serum potassium and creatinine 2–4 weeks after initiating thiazide therapy to detect hypokalemia, hyperuricemia, or changes in renal function—common dose-related adverse effects. 1, 2
• Monitor for orthostatic hypotension, particularly in this 71-year-old patient, as older adults are at increased risk despite evidence from SPRINT and HYVET showing that intensive BP control does not exacerbate orthostatic symptoms in community-dwelling elderly. 1

If Blood Pressure Remains Uncontrolled on Dual Therapy

• Add a calcium channel blocker (amlodipine 5–10 mg daily) as the third agent to achieve guideline-recommended triple therapy (beta-blocker + diuretic + CCB). 1, 2
• The combination of metoprolol + thiazide + amlodipine targets three complementary mechanisms: cardiac output reduction, volume depletion, and arterial vasodilation. 2
• If BP remains ≥140/90 mm Hg after optimized triple therapy, add spironolactone 25–50 mg daily as the preferred fourth-line agent for resistant hypertension, which provides additional reductions of approximately 20–25/10–12 mm Hg. 1, 2

Alternative Consideration: Switching from Metoprolol

• If the patient has no compelling indication for beta-blocker therapy (no history of MI, heart failure, angina, or atrial fibrillation), consider replacing metoprolol with an ACE inhibitor or ARB plus a thiazide diuretic or calcium channel blocker, as these combinations are more effective first-line regimens for uncomplicated hypertension in older adults. 1
• For a 71-year-old patient, initiating dual therapy with two first-line agents (ACE-I/ARB + CCB, or ACE-I/ARB + thiazide, or CCB + thiazide) would be appropriate given the stage 2 hypertension, though this should be done cautiously with careful monitoring for orthostatic hypotension. 1

Special Considerations for Elderly Patients (Age 71)

• Older adults ≥65 years should be treated to the same BP targets as younger patients (<130/80 mm Hg if tolerated, minimum <140/90 mm Hg), based on evidence from SPRINT and HYVET demonstrating benefit even in those >80 years old. 1
• For patients ≥65 years, the 2024 ESC guidelines recommend a systolic BP target of 130–139 mm Hg, with more lenient targets (e.g., <140 mm Hg) considered for those ≥85 years or with significant frailty. 1
• Initiation of dual therapy should be undertaken cautiously in older persons, with careful monitoring for orthostatic hypotension and falls, though RCTs have shown that improved BP control does not increase fall risk in community-dwelling elderly. 1
• SPRINT excluded patients with standing BP <110 mm Hg at entry, so orthostatic BP should be checked before and during treatment intensification. 1

Lifestyle Modifications (Adjunctive)

• Sodium restriction to <2 g/day provides a 5–10 mm Hg systolic reduction and enhances the efficacy of thiazide diuretics. 1, 2
• Regular aerobic exercise (≥30 minutes on 5–7 days/week) reduces BP by approximately 4/3 mm Hg. 1
• Weight management targeting BMI 20–25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) contributes additional BP reduction. 1
• Alcohol limitation to <14 units/week for men (<100 g/week of pure alcohol) is recommended. 1

Critical Pitfalls to Avoid

• Do not continue metoprolol monotherapy at the current dose without adding a second agent; stage 2 hypertension requires dual therapy for adequate control. 1
• Do not simply increase metoprolol dose as the primary strategy; combination therapy with agents from different classes is more effective than monotherapy dose escalation. 1, 2
• Do not delay treatment intensification; stage 2 hypertension warrants prompt action within 2–4 weeks to reduce cardiovascular risk. 1
• Do not assume treatment failure without first confirming medication adherence and excluding white-coat hypertension with home BP monitoring (target <135/85 mm Hg) or 24-hour ambulatory monitoring (target <130/80 mm Hg). 1, 5
• Do not withhold appropriate treatment intensification solely based on age; no randomized trial of BP lowering in persons >65 years has ever shown harm or less benefit for older versus younger adults. 1