A 69-year-old obese man (body mass index 31 kg/m²) with stage 2 hypertension (147/86 mmHg), mild benign prostatic hyperplasia, and hyperlipidemia treated with simvastatin, who has normal laboratory studies, a normal electrocardiogram, and no evidence of target‑organ damage—what is the most appropriate next step in management?

Management of Stage 2 Hypertension in a 69-Year-Old Man

This patient requires immediate initiation of combination antihypertensive drug therapy plus lifestyle modifications, not lifestyle modifications alone or delayed reassessment.

Blood Pressure Classification and Risk Assessment

• This patient has stage 2 hypertension (147/86 mmHg, with multiple readings around 150/84 mmHg), defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg by the 2017 ACC/AHA guidelines 1.

• At age 69 with obesity (BMI 31 kg/m²) and hyperlipidemia, his 10-year ASCVD risk almost certainly exceeds 10%, placing him in a high-risk category that mandates pharmacological intervention 1.

• The absence of target organ damage (normal ECG, no proteinuria, no left ventricular hypertrophy) does not eliminate the need for drug therapy in stage 2 hypertension 1.

Treatment Recommendation: Combination Therapy

Adults with stage 2 hypertension should be initiated on a combination of nonpharmacological and antihypertensive drug therapy with 2 agents of different classes, with repeat BP evaluation in 1 month 1.

Why Amlodipine is the Optimal Choice (Answer C)

• Amlodipine (a calcium channel blocker) is specifically advantageous for this patient because:
  • It is FDA-approved for hypertension treatment and reduces cardiovascular morbidity and mortality 2.
  • Calcium channel blockers are particularly effective in older adults and have no adverse metabolic effects 1.
  • Amlodipine is beneficial for benign prostatic hyperplasia (BPH), as calcium channel blockers can reduce lower urinary tract symptoms, making it ideal for this patient's comorbidity 2.
  • It has no negative interaction with simvastatin at standard doses 2.

Why Beta-Blockers are NOT Appropriate (Answer D is Wrong)

• Beta-blockers should NOT be first-line therapy for uncomplicated hypertension in this patient 1.
• Beta-blockers may induce new-onset diabetes, particularly concerning in an obese patient with metabolic risk factors 1.
• Beta-blockers have dyslipidemic effects and are less effective than other agents in preventing cardiovascular events when used as monotherapy 1.
• This patient has no compelling indication for beta-blockers (no heart failure, no recent MI, no angina) 1.

Why Lifestyle Modifications Alone are Insufficient (Answer B is Wrong)

• Lifestyle modifications alone are only appropriate for stage 1 hypertension with ASCVD risk <10% 1.
• This patient has stage 2 hypertension, which mandates immediate pharmacological therapy regardless of ASCVD risk 1.
• Delaying drug therapy in stage 2 hypertension increases cardiovascular risk unnecessarily 1.

Why Delayed Reassessment is Inappropriate (Answer A is Wrong)

• Repeat BP evaluation in 4 months is only appropriate for elevated BP or stage 1 hypertension with low ASCVD risk (<10%) 1.
• Stage 2 hypertension requires evaluation within 1 month of diagnosis, not 4 months 1.
• This patient's elevated cardiovascular risk (age 69, obesity, hyperlipidemia) demands prompt intervention 1.

Recommended Treatment Algorithm

1. Initiate amlodipine 5 mg daily as first-line therapy 2.

   • May titrate to 10 mg daily if BP remains above target after 2-4 weeks 2.

2. Add a second agent if BP remains ≥130/80 mmHg on amlodipine monotherapy:

   • Consider a thiazide diuretic (chlorthalidone 12.5-25 mg daily) or ACE inhibitor/ARB 1.
   • Avoid combining ACE inhibitor with ARB, as dual RAS blockade increases adverse events without benefit 1, 3.

3. Implement lifestyle modifications concurrently 1:

   • Sodium restriction to <1,500 mg/day 4.
   • Weight loss targeting BMI <25 kg/m² 4.
   • DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy 4.
   • Physical activity 90-150 minutes/week 4.
   • Alcohol limitation to ≤1 drink per day 4.

4. Target BP <130/80 mmHg to reduce cardiovascular events 1, 4.

5. Repeat BP evaluation in 1 month to assess response and adjust therapy 1.

Critical Clinical Pitfalls

• Do not use immediate-release nifedipine, which causes unpredictable precipitous BP drops 4.
• Monitor for orthostatic hypotension when combining amlodipine with tamsulosin (α-1 blocker for BPH), as both can cause vasodilation 3.
• Avoid thiazide diuretics at high doses in this patient with hyperlipidemia, as they have dyslipidemic and diabetogenic effects 1.
• Do not delay treatment while pursuing extensive secondary hypertension workup in a 69-year-old with typical presentation 5, 6.

Follow-Up and Monitoring

• Recheck BP in 1 month after initiating therapy 1.
• Implement home BP monitoring with twice-daily readings to guide therapy adjustments 3.
• Monitor serum electrolytes and renal function if a thiazide diuretic is added 7.
• Continue simvastatin for cardiovascular risk reduction 3.