In a 59-year-old female with hypertension and tremor on atenolol 25 mg daily who remains hypertensive, what is the best next management?

Management of Uncontrolled Hypertension in a 59-Year-Old Female on Atenolol 25mg

Increase atenolol to 50–100 mg once daily as the first step, and if blood pressure remains uncontrolled after 2–4 weeks, add a calcium-channel blocker (amlodipine 5–10 mg daily) or a thiazide-like diuretic (chlorthalidone 12.5–25 mg daily) to achieve guideline-recommended dual therapy. 1

Current Situation Assessment

• Your patient has uncontrolled hypertension on atenolol 25 mg daily, which is a subtherapeutic dose; the standard effective dose range for atenolol in hypertension is 50–200 mg once daily, with most patients responding to 100 mg. 2, 3
• Atenolol 25 mg is below the dose that produces maximum hypotensive effect (typically 100 mg), so dose optimization should precede adding a second agent. 3
• The tremor indication for atenolol is appropriate, as beta-blockers effectively control essential tremor, but blood pressure control remains the priority outcome. 4

Step 1: Optimize Atenolol Dosing

• Increase atenolol to 50 mg once daily immediately, then reassess blood pressure in 2 weeks. 2, 5
• If blood pressure remains ≥140/90 mmHg after 2 weeks on atenolol 50 mg, increase to 100 mg once daily. 2, 3
• Atenolol demonstrates a dose-related blood pressure response over the range of 50–200 mg, with the maximum hypotensive effect typically achieved at 100 mg once daily. 3
• Once-daily dosing with atenolol provides 24-hour blood pressure control and is therapeutically equivalent to divided dosing, improving adherence. 5

Step 2: Add a Second Agent if Monotherapy Fails

First-Line Add-On Option: Calcium-Channel Blocker

• Add amlodipine 5 mg once daily if blood pressure remains ≥140/90 mmHg after optimizing atenolol to 100 mg. 1
• The combination of a beta-blocker plus a calcium-channel blocker provides complementary mechanisms—heart rate/contractility reduction plus arterial vasodilation—and is well-tolerated. 1
• Amlodipine does not cause bradycardia and is safe to combine with atenolol, unlike non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) which should be avoided due to additive negative chronotropic effects. 1

Alternative Add-On Option: Thiazide-Like Diuretic

• Add chlorthalidone 12.5–25 mg once daily as an alternative second agent if calcium-channel blockers are contraindicated or not tolerated. 1, 6
• The combination of atenolol plus chlorthalidone has been extensively studied and produces additive blood pressure reductions, though the effect is slightly less than the sum of individual effects. 6
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action (24–72 hours) and superior cardiovascular outcome data. 1

Blood Pressure Targets and Monitoring

• Target blood pressure is <130/80 mmHg for most adults, with a minimum acceptable goal of <140/90 mmHg. 1
• Re-measure blood pressure 2–4 weeks after each dose adjustment, aiming to achieve target within 3 months of therapy modification. 1
• Monitor heart rate to ensure it remains >50 bpm; excessive bradycardia (<50 bpm) may limit further atenolol dose escalation. 2

Step 3: Triple Therapy if Dual Therapy Fails

• If blood pressure remains ≥140/90 mmHg on atenolol 100 mg plus either amlodipine or chlorthalidone, add the third agent from the remaining class to form triple therapy (beta-blocker + calcium-channel blocker + thiazide diuretic). 1
• This triple combination targets three complementary mechanisms: heart rate/contractility reduction, arterial vasodilation, and volume reduction. 1

Special Considerations for This Patient

Tremor Management

• Atenolol effectively controls essential tremor at doses of 50–100 mg daily, so dose escalation will simultaneously address both hypertension and tremor. 4
• If tremor control is inadequate on atenolol 100 mg, consider switching to propranolol (which has stronger tremor-suppressing effects) rather than further increasing atenolol beyond 100 mg for hypertension. 4

Age-Related Dosing (59 Years Old)

• At age 59, this patient does not require elderly-specific dose adjustments unless renal impairment is present. 2
• Standard adult dosing of atenolol (50–200 mg daily) is appropriate for this age group. 2

Critical Pitfalls to Avoid

• Do not add a second antihypertensive agent before optimizing atenolol to at least 100 mg daily, as this violates the stepwise dose-optimization principle and exposes the patient to unnecessary polypharmacy. 1, 3
• Do not discontinue atenolol abruptly if switching to another agent, as sudden beta-blocker withdrawal can precipitate rebound hypertension, angina, or arrhythmias; taper over 1–2 weeks if discontinuation is necessary. 2
• Do not combine atenolol with non-dihydropyridine calcium-channel blockers (diltiazem, verapamil), as this increases the risk of severe bradycardia and heart block. 1
• Do not assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance. 1

Monitoring After Dose Escalation

• Check blood pressure and heart rate 2 weeks after increasing atenolol to 50 mg, then again 2 weeks after any further dose adjustment. 1, 5
• If adding a thiazide diuretic, check serum potassium and creatinine 2–4 weeks after initiation to detect hypokalemia or renal function changes. 1
• Assess for beta-blocker side effects including fatigue, cold extremities, and exercise intolerance, which may limit dose escalation. 4

Lifestyle Modifications (Adjunct to Pharmacotherapy)

• Sodium restriction to <2 g/day yields a 5–10 mmHg systolic reduction and enhances the efficacy of all antihypertensive classes. 1
• Regular aerobic exercise (≥30 minutes most days) lowers blood pressure by approximately 4/3 mmHg. 1
• Weight loss if overweight (BMI ≥25 kg/m²)—losing approximately 10 kg reduces blood pressure by about 6/4.6 mmHg. 1
• Limit alcohol intake to ≤1 drink per day for women. 1