What is the appropriate management of a 78‑year‑old woman with uncontrolled stage‑2 hypertension (blood pressure 180/93 mm Hg) and chronic back pain from scoliosis who is scheduled for pain‑relief injections?

Management of Stage 2 Hypertension in a 78-Year-Old Woman

This patient requires immediate initiation of combination antihypertensive therapy with two first-line agents, targeting a blood pressure of 120-129/70-79 mmHg, while her scheduled pain injections can proceed once blood pressure is adequately controlled.

Immediate Blood Pressure Management

Classification and Urgency

• Blood pressure of 180/93 mmHg represents Stage 2 hypertension requiring prompt treatment 1
• This is not a hypertensive emergency (BP <220/110 mmHg without acute end-organ damage), so oral therapy is appropriate rather than IV medications 1
• The patient should be evaluated and treatment initiated within 1 month, with reassessment in 1 month after starting therapy 1

Initial Pharmacological Approach

Start combination therapy immediately with two agents from different classes 1:

• Preferred combination: RAS blocker (ACE inhibitor or ARB) + calcium channel blocker (CCB) 1
• Alternative combination: RAS blocker + thiazide-like diuretic (chlorthalidone or indapamide) 1
• Use a single-pill combination to improve adherence 1, 2

Specific regimen examples 3:

• Amlodipine 5mg + lisinopril 10mg once daily, OR
• Amlodipine 5mg + losartan 50mg once daily, OR
• Chlorthalidone 12.5mg + lisinopril 10mg once daily

Target Blood Pressure

Aim for systolic BP 120-129 mmHg and diastolic BP 70-79 mmHg 1, 2:

• This target applies to patients up to age 85 years if treatment is well tolerated 1, 2
• At age 78, she is not in the ≥85 year category where more conservative targets might apply 1
• If she cannot tolerate this target due to symptoms, follow the "as low as reasonably achievable" (ALARA) principle 1, 2

Escalation Strategy if Initial Therapy Inadequate

Step 3: Triple Therapy

If BP remains uncontrolled after 2-4 weeks on dual therapy, escalate to triple combination 1, 2:

• RAS blocker + CCB + thiazide-like diuretic 1
• Preferably as a single-pill combination 1

Step 4: Resistant Hypertension

If BP remains ≥140/90 mmHg on optimal doses of three drugs 1:

• Add low-dose spironolactone 25mg once daily (if serum potassium <4.6 mmol/L) 1
• Check electrolytes and renal function within 1 month 1
• If spironolactone not tolerated: consider eplerenone, beta-blocker (bisoprolol), or alpha-blocker (doxazosin) 1

Special Considerations for Elderly Patients

Orthostatic Hypotension Monitoring

Measure both sitting and standing blood pressures at each visit 2, 4:

• Elderly patients have reduced baroreflex sensitivity increasing vulnerability to orthostatic hypotension 4
• Standing BP measurements should guide treatment decisions 1
• Symptomatic orthostatic hypotension may require dose adjustment 1

Titration Approach

• Start with lower doses and titrate more slowly than in younger patients 4, 5
• Monitor for cognitive impairment, falls, and electrolyte abnormalities 4, 5
• Reassess within 2-4 weeks after medication changes 2

Pain Management and Scheduled Injections

Proceeding with Pain Injections

The scheduled pain injections for scoliosis-related chronic pain can proceed once BP is controlled to <180/110 mmHg 1:

• There is no absolute contraindication to epidural or facet injections at current BP level 1
• However, better BP control reduces perioperative cardiovascular risk 1
• Ideally, achieve BP <140/90 mmHg before elective procedures 1

Pain Management Considerations

• Epidural steroid injections and facet injections provide short-term pain relief (2 weeks to 2 months) for chronic back pain from degenerative disease 1
• NSAIDs used for pain management may interfere with BP control and should be avoided or minimized 3
• Acetaminophen is preferred for pain management in hypertensive patients 3

Lifestyle Modifications (Concurrent with Medications)

Initiate immediately alongside pharmacotherapy 1, 3:

• Sodium restriction to <2g/day (most important for elderly patients) 1
• DASH diet or Mediterranean diet pattern 1, 3
• Potassium supplementation if not contraindicated by renal function 3
• Weight loss if BMI >25 kg/m² 1
• Limit alcohol to <100g/week 1
• Regular physical activity as tolerated given scoliosis 1

Monitoring Plan

Follow-up Schedule

• Recheck BP in 1 month after initiating therapy 1, 2
• Measure electrolytes and renal function 2-4 weeks after starting RAS blocker or diuretic 1, 2
• Aim to achieve target BP within 3 months 2
• Consider home BP monitoring to assess treatment efficacy 2

Common Pitfalls to Avoid

• Therapeutic inertia: Failing to intensify treatment when BP remains uncontrolled is the most common error 2
• Starting with monotherapy in Stage 2 hypertension delays BP control 1
• Using twice-daily dosing regimens that reduce adherence 2
• Failing to check standing BP in elderly patients 2, 4
• Delaying necessary procedures indefinitely due to hypertension when BP is not severely elevated 1
• Combining two RAS blockers (ACE inhibitor + ARB), which is contraindicated 1