In an 80‑year‑old man weighing 82 kg with serum creatinine 99.8 µmol/L (≈1.1 mg/dL), estimated glomerular filtration rate 70–80 mL/min, left‑ventricular ejection fraction 63 % (normal) and hypertension, who is taking hydralazine 12.5 mg twice daily and an unidentified medication “tandoori” 2 mg daily, what antihypertensive regimen adjustments are recommended?

Antihypertensive Regimen Adjustment for an 80-Year-Old with Uncontrolled Hypertension

Add amlodipine 2.5–5 mg once daily to the current regimen, as this patient requires intensification with a calcium channel blocker given his preserved ejection fraction, adequate renal function, and uncontrolled hypertension on hydralazine monotherapy. 1

Current Regimen Assessment

• Hydralazine 12.5 mg twice daily is an unusual choice for primary hypertension management in 2025; it is reserved for heart failure with reduced ejection fraction (particularly in African-American patients) or as a last-resort agent when standard therapies fail 2, 3
• With an LVEF of 63%, this patient has preserved systolic function and does not have an indication for hydralazine 2
• Hydralazine carries significant risks in elderly patients, including drug-induced lupus, ANCA-associated vasculitis with severe acute kidney injury, and unfavorable long-term outcomes 4
• The medication listed as "tandoori 2 mg daily" cannot be identified; clarify this with the patient or pharmacy records before making changes

Recommended Treatment Algorithm

Step 1: Add a Dihydropyridine Calcium Channel Blocker

• Start amlodipine 2.5 mg once daily and titrate to 5 mg after 2–4 weeks if blood pressure remains ≥140/90 mmHg 1, 5
• Dihydropyridine CCBs are specifically recommended for patients ≥80 years because they do not cause bradycardia, are well-tolerated, and effectively reduce stroke risk 1, 5
• The low starting dose (2.5 mg) minimizes vasodilatory side effects such as peripheral edema and dizziness 1

Step 2: Consider Transitioning Away from Hydralazine

• Once blood pressure is controlled on amlodipine, gradually discontinue hydralazine to eliminate the risk of drug-induced vasculitis and lupus-like syndrome 4
• If a second agent is still needed after stopping hydralazine, add a thiazide-like diuretic (chlorthalidone 12.5 mg daily or indapamide 1.25 mg daily) rather than restarting hydralazine 1, 6

Step 3: Add an ACE Inhibitor or ARB if Triple Therapy is Required

• If blood pressure remains ≥140/90 mmHg on amlodipine plus a diuretic, add lisinopril 5 mg once daily (reduced dose due to age ≥80 years) 7, 1
• ACE inhibitors are renally protective and reduce cardiovascular events, but require monitoring of serum creatinine and potassium within 1–2 weeks of initiation 8, 7
• With a baseline creatinine of 99.8 µmol/L (≈1.1 mg/dL) and estimated GFR 70–80 mL/min, no dose adjustment of lisinopril is required 7

Blood Pressure Targets for This Patient

• Primary target: systolic 120–129 mmHg if tolerated, with a minimum acceptable target of <140/90 mmHg 1
• For functionally independent adults ≥80 years, the 2024 European Society of Cardiology recommends the same targets as younger patients unless frailty or intolerance dictates otherwise 1
• Measure blood pressure in both sitting and standing positions at every visit to detect orthostatic hypotension, which is common in octogenarians 1, 5

Critical Monitoring Parameters

• Recheck blood pressure within 2–4 weeks of adding amlodipine 1
• Assess for peripheral edema (occurs in 10–15% of elderly patients on amlodipine) and adjust dose or add a diuretic if problematic 1
• Monitor serum creatinine and potassium if an ACE inhibitor or ARB is added; a creatinine increase up to 20% is acceptable and does not indicate progressive renal damage 8
• Screen for orthostatic hypotension by measuring blood pressure after 1 minute and 3 minutes of standing 1

Why Not Other Options?

• Beta-blockers are less effective than CCBs or diuretics for stroke prevention in the elderly and should not be used as first-, second-, or third-line agents unless a compelling indication exists (e.g., heart failure, recent MI, angina) 1
• Thiazide diuretics alone are acceptable but less effective than CCBs in very elderly patients with isolated systolic hypertension 5
• Continuing hydralazine exposes the patient to unnecessary risk of ANCA vasculitis, drug-induced lupus, and severe AKI without evidence of benefit in hypertension management 4

Common Pitfalls to Avoid

• Do not withhold treatment based on age alone; the 2024 ESC guidelines explicitly recommend lifelong antihypertensive therapy in patients >85 years if tolerated 1
• Do not start with high doses or escalate rapidly; elderly patients require gradual titration to avoid hypotension, falls, and treatment discontinuation 8, 5
• Do not ignore the unidentified "tandoori" medication; verify this with the patient or pharmacy to rule out drug interactions or duplicative therapy
• Do not assume hydralazine is appropriate for routine hypertension; it is a last-resort agent with a narrow indication profile 2, 4