Which antihypertensives should be held to prevent postural hypotension in a patient taking nitrates for angina, metoprolol (beta blocker), perindopril (angiotensin-converting enzyme inhibitor), and spironolactone (aldosterone antagonist)?

From the Guidelines

To prevent postural hypotension, it is recommended to hold or reduce the dose of perindopril and nitrates temporarily before activities requiring position changes, as these medications can cause significant vasodilation and worsen orthostatic hypotension 1. When considering the management of antihypertensive medications to prevent postural hypotension, it's crucial to assess the potential impact of each medication on blood pressure regulation.

• Perindopril, an ACE inhibitor, and nitrates, used for angina, are known to cause vasodilation, which can significantly contribute to orthostatic hypotension.
• Metoprolol, a beta-blocker, and spironolactone, a potassium-sparing diuretic, may also contribute to postural hypotension but are generally considered less problematic in this context. The management strategy should include:
• Holding the morning dose of perindopril and nitrates or taking them after activities that require significant position changes.
• Ensuring the patient changes positions slowly, moving from lying to sitting for 1-2 minutes before standing to mitigate the risk of falls.
• Maintaining adequate hydration, especially in hot weather, to prevent dehydration-induced hypotension.
• Monitoring blood pressure in different positions (lying, sitting, standing) to assess the severity of postural changes and guide further management. It's essential to discuss any long-term modifications of these medications with the prescribing physician to balance the risk of falls against the cardiovascular benefits they provide, as they are crucial for the patient's cardiac health 1.

From the FDA Drug Label

Hypotension: Like other ACE inhibitors, perindopril erbumine tablets can cause symptomatic hypotension. In patients at risk of excessive hypotension, perindopril erbumine tablets therapy should be started under very close medical supervision Patients should be followed closely for the first two weeks of treatment and whenever the dose of perindopril erbumine tablets and/or diuretic is increased. If excessive hypotension occurs, the patient should be placed immediately in a supine position and, if necessary, treated with an intravenous infusion of physiological saline Perindopril erbumine tablets treatment can usually be continued following restoration of volume and blood pressure Beta-adrenergic blockers may also potentiate the postural hypotensive effect of the first dose of prazosin, probably by preventing reflex tachycardia On the contrary, beta adrenergic blockers may also potentiate the hypertensive response to withdrawal of clonidine in patients receiving concomitant clonidine and beta-adrenergic blocker.

The patient is on metoprolol, perindopril, and spironolactone. To prevent postural hypotension, consider holding:

• Perindopril: an ACE inhibitor that can cause symptomatic hypotension, especially in patients at risk of excessive hypotension.
• Metoprolol: a beta-blocker that can potentiate the postural hypotensive effect of certain medications. It is also important to consider the patient's current medication regimen, including nitrates for angina, when making decisions about holding antihypertensives to prevent postural hypotension 2 3.

From the Research

Antihypertensives to Hold for Preventing Postural Hypotension

To prevent postural hypotension in a patient on nitrates for angina, metoprolol, perindopril, and spironolactone, consider the following:

• Perindopril: As an ACE inhibitor, perindopril can cause a significant reduction in blood pressure, especially after the first dose 4. Holding this medication may help prevent postural hypotension.
• Metoprolol: As a beta-blocker, metoprolol can also contribute to hypotension, especially when combined with other antihypertensive agents 5. Withholding metoprolol may be necessary to prevent postural hypotension.
• Spironolactone: Although spironolactone is a potassium-sparing diuretic, it can still contribute to hypotension, especially when used in combination with other antihypertensive agents. However, there is limited evidence to suggest that holding spironolactone is necessary to prevent postural hypotension.

Considerations for Holding Antihypertensives

When considering which antihypertensives to hold, take into account the following:

• Combination therapy: The patient is on multiple antihypertensive agents, which increases the risk of postural hypotension. Holding one or more of these medications may be necessary to prevent this complication.
• Individual patient factors: The patient's individual response to each medication, as well as their overall health status, should be considered when deciding which antihypertensives to hold.
• Monitoring and adjustment: Close monitoring of the patient's blood pressure and adjustment of their antihypertensive regimen as needed can help prevent postural hypotension.

Evidence for Antihypertensive Therapy

Studies have shown that perindopril and metoprolol are effective antihypertensive agents, but they can also contribute to hypotension 6, 7, 5, 8. The decision to hold these medications should be based on individual patient factors and close monitoring of their blood pressure.