What can be done to improve stage 2 hypertension in a 72-year-old female patient on losartan (angiotensin II receptor antagonist) 25mg daily and propranolol (beta blocker) 20mg twice weekly, with bradycardia (heart rate in the high 40s to low 50s)?

From the Guidelines

For this 72-year-old female patient with persistent stage 2 hypertension on suboptimal therapy and bradycardia, I recommend optimizing her antihypertensive regimen while addressing the bradycardia concern. First, increase losartan to 50mg daily, as the current 25mg dose is below the typical therapeutic range, as suggested by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. Discontinue propranolol, as beta-blockers are contributing to her bradycardia and the twice weekly dosing is inappropriate for hypertension management. Instead, add amlodipine 5mg daily, a calcium channel blocker that effectively lowers blood pressure without worsening bradycardia, as recommended by the prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. If blood pressure remains uncontrolled after 2-4 weeks, consider adding a thiazide diuretic like hydrochlorothiazide 12.5mg daily. Monitor blood pressure, heart rate, renal function, and electrolytes 1-2 weeks after each medication change. The patient's bradycardia warrants further evaluation to determine its cause, which could be medication-related or indicate underlying conduction system disease. This approach addresses both the inadequate blood pressure control and respects the bradycardia limitation by using agents that won't further slow her heart rate while providing 24-hour blood pressure coverage. Key considerations include:

• Initiating therapy with two antihypertensive agents from different classes for stage 2 hypertension, as recommended by the guidelines 1
• Using thiazide diuretics and calcium-channel blockers as preferred options for first-line therapy in most U.S. adults, including those with stage 2 hypertension 1
• Monitoring and adjusting the regimen until control is achieved, with a goal of less than 130/80 mm Hg, as suggested by the guidelines 1

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. Doses of 50 mg, 100 mg and 150 mg once daily gave statistically significant systolic/diastolic mean decreases in blood pressure, compared to placebo in the range of 5.5 to 10.5/3.5 to 7. 5 mmHg, with the 150-mg dose giving no greater effect than 50 mg to 100 mg.

The patient is currently taking losartan 25mg daily, which is below the recommended starting dose of 50mg once daily. Considering the patient's stage 2 hypertension and the fact that the current dose is not effective, increasing the dose of losartan to 50mg once daily may be beneficial. However, the patient's bradycardia should be taken into account when making any changes to their medication regimen, as propranolol is also being used. It is essential to monitor the patient's blood pressure and heart rate closely when adjusting their medication. 2 2

• Key considerations:
  • Increase losartan dose to 50mg once daily
  • Monitor blood pressure and heart rate closely
  • Consider the patient's bradycardia when making any changes to their medication regimen

From the Research

Patient's Current Medication and Condition

The patient is currently taking losartan 25mg daily and propranolol 20mg twice weekly, and is still stage 2 hypertensive. The patient also has bradycardia with a heart rate in the high 40s to low 50s.

Potential Treatment Options

• According to 3, combination therapy with at least two antihypertensive agents is often necessary to achieve adequate blood pressure control. The patient is already taking two medications, but the dosages and types of medications may need to be adjusted.
• The study 4 compared the effects of losartan and amlodipine on blood pressure variability in essential hypertensive patients. The results suggested that amlodipine may be better at lowering blood pressure variability than losartan.
• The research 5 found that increasing from single-class to dual-class antihypertensive therapy was associated with a 42% increased odds of achieving blood pressure control. However, the effect was attenuated as the number of baseline antihypertensive classes increased.
• The study 6 found that the combination of amlodipine and losartan had synergistic antihypertensive effects and improved arterial endothelium-dependent relaxation in spontaneously hypertensive rats.
• The study 7 found that combining an angiotensin-receptor blocker (ARB) with either hydrochlorothiazide (HCTZ) or a calcium-channel blocker (CCB) improved left ventricular relaxation in patients with hypertension and diastolic dysfunction.

Considerations for the Patient's Treatment

• The patient's bradycardia may be a concern when adjusting their medication regimen, as some antihypertensive medications can exacerbate bradycardia.
• The patient is already taking a beta blocker (propranolol), which can contribute to bradycardia. Adjusting the dosage or type of beta blocker may be necessary.
• Adding a diuretic, such as hydrochlorothiazide, or a calcium channel blocker, such as amlodipine, to the patient's medication regimen may be considered to improve blood pressure control, as suggested by 3, 4, and 7.
• The combination of losartan and amlodipine may be considered, as suggested by 6, but the patient's bradycardia and current medication regimen should be taken into account.