What are the recommended medication and follow‑up adjustments for a 76‑year‑old man with coronary artery disease post‑PCI, hypertension, hyperlipidemia, well‑controlled LDL, elevated systolic blood pressure, on high‑intensity statin, clopidogrel, metoprolol, losartan, and asymptomatic?

Blood Pressure Management Recommendations

Add amlodipine 5 mg daily to his current regimen of metoprolol 25 mg and losartan 100 mg, rather than HCTZ, to achieve better blood pressure control in this patient with coronary artery disease and prior PCI. 1

Rationale for Blood Pressure Target

• Target blood pressure should be <140/90 mm Hg, with consideration for <130/80 mm Hg given his history of PCI and coronary artery disease, which places him at high cardiovascular risk. 1
• His current readings of 140/80 and 144/70 are at or above the threshold requiring intervention. 1

Medication Selection Strategy

Why Not HCTZ (as initially planned):

• Thiazide diuretics have meager evidence for improved outcomes compared with other agents in hypertension with coronary artery disease. 1
• Beta-blockers, ACE inhibitors/ARBs, and calcium channel blockers are preferred in CAD patients based on outcome data. 1

Optimal Medication Approach:

• Add a long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) as the next agent, which has established cardiovascular outcome benefits in CAD patients. 1
• His current regimen already includes appropriate first-line agents: beta-blocker (metoprolol) and ARB (losartan). 1
• Consider increasing metoprolol dose from 25 mg to 50 mg twice daily if heart rate permits (currently 63 bpm allows room for uptitration). 2, 1

Antiplatelet Therapy Continuation

Continue clopidogrel 75 mg daily indefinitely given his stenting occurred 3 years ago with drug-eluting stents. 3

• He is now beyond the critical 12-month period post-PCI, but continuation of P2Y12 inhibitor therapy beyond 12 months is reasonable in patients with high ischemic risk and low bleeding risk. 3
• His asymptomatic status with a known untreated mid-RCA lesion that is hemodynamically significant places him at ongoing ischemic risk. 3
• Aspirin should be continued indefinitely at 81 mg daily (lower dose preferred for long-term therapy to reduce bleeding risk). 2, 3

Lipid Management

Continue current high-intensity statin therapy with LDL-C well-controlled at 42 mg/dL. 4, 5

• This LDL level is excellent and below the 50-70 mg/dL target range. 4
• No adjustment needed in statin therapy. 4, 5

Follow-Up Interval

See patient back in 2-4 weeks to assess blood pressure response to medication adjustment, rather than waiting 3 months. 1

• Once blood pressure is at goal, return to 3-month follow-up intervals. 1
• Check basic metabolic panel at next visit to monitor potassium and renal function given triple therapy with beta-blocker, ARB, and planned addition of calcium channel blocker. 1

Common Pitfalls to Avoid

• Do not discontinue clopidogrel prematurely despite being 3 years post-PCI, as he has an untreated hemodynamically significant RCA lesion representing ongoing high ischemic risk. 3
• Avoid adding HCTZ as the third antihypertensive when calcium channel blockers have superior outcome data in CAD patients. 1
• Do not delay blood pressure optimization – his systolic readings consistently above 140 mm Hg require prompt intervention given his CAD. 1
• Ensure contrast allergy is well-documented in case future cardiac catheterization is needed for the RCA lesion if he develops symptoms. 1