What is the optimal approach to control blood pressure in a 69‑year‑old woman with heart failure who is currently taking metoprolol succinate 25 mg daily, isosorbide mononitrate 30 mg daily, furosemide 40 mg daily, hydrochlorothiazide 25 mg daily, and lisinopril 10 mg daily?

Blood Pressure Control in a 69-Year-Old Woman with Heart Failure on Multiple Medications

This patient's regimen is suboptimal and potentially dangerous: she is taking both a loop diuretic (furosemide 40mg) and a thiazide (HCTZ 25mg) together, which dramatically increases the risk of severe electrolyte depletion, renal dysfunction, and mortality, while her ACE inhibitor (lisinopril 10mg) and beta-blocker (metoprolol succinate 25mg) are both at subtherapeutic doses that provide inadequate cardioprotection. 1

Immediate Medication Adjustments Required

Discontinue hydrochlorothiazide 25mg immediately. The combination of furosemide plus HCTZ creates excessive diuretic burden, leading to hypokalemia, hyponatremia, worsening renal function, and increased mortality without proven benefit over optimized loop diuretic monotherapy. 2 When diuresis is inadequate in heart failure, uptitration of the loop diuretic is safer and more effective than adding a thiazide. 3, 2

Stop isosorbide mononitrate 30mg daily. Direct vasodilators have no specific role in chronic heart failure management and lack survival benefit (Level A evidence). 1 This medication is contributing to polypharmacy without improving outcomes. 3

Optimize Guideline-Directed Medical Therapy (GDMT)

ACE Inhibitor Titration

Increase lisinopril from 10mg to 20mg daily immediately, with a target dose of 20-40mg daily. 3 The current 10mg dose is below the evidence-based target that reduces cardiovascular mortality and heart failure hospitalizations. 3 Start with a low dose and build up to recommended maintenance dosages shown to be effective in large trials. 3

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals. 3
• Tolerate a creatinine rise up to 25-30% (or an absolute value <2.5 mg/dL) without discontinuation. 1
• If renal function deteriorates substantially beyond these thresholds, reduce the dose rather than stopping treatment. 3

Beta-Blocker Titration

Increase metoprolol succinate from 25mg to 50mg daily, with a target dose of 200mg daily. 3 Beta-blockers are recommended for all patients with stable heart failure and reduced ejection fraction (NYHA class II-IV) on standard treatment including diuretics and ACE inhibitors (Level A). 3

• Double the dose at not less than 2-week intervals. 3
• Monitor heart rate, blood pressure, clinical status (symptoms, signs of congestion, body weight). 3
• If marked fatigue or bradycardia (<50 beats/min with worsening symptoms), halve the dose temporarily. 3
• Temporary symptomatic deterioration may occur (20-30% of cases) during initiation/up-titration but can usually be managed by adjustment of other medications. 3

Diuretic Management

Continue furosemide 40mg daily as the sole diuretic. 3 Loop diuretics are essential for symptomatic treatment when fluid overload is present (Level A). 3

• If diuresis remains inadequate after stopping HCTZ, increase furosemide dose before considering combination therapy. 3
• Administer loop diuretics twice daily if persistent fluid retention occurs. 3
• Only add a thiazide back synergistically with the loop diuretic if severe fluid retention persists despite high-dose furosemide, with frequent measurement of creatinine and electrolytes. 3

Consider Adding Aldosterone Antagonist

Add spironolactone 12.5-25mg daily if the patient has NYHA class III-IV symptoms, provided baseline potassium is <5.0 mmol/L and creatinine is <2.5 mg/dL. 3, 1 Aldosterone antagonism is recommended in advanced heart failure to improve survival and morbidity (Level B). 3

• Check serum potassium and creatinine after 4-6 days, then recheck every 5-7 days until potassium values are stable. 3, 1
• If potassium rises to 5.0-5.5 mmol/L, reduce the dose by 50%; discontinue if >5.5 mmol/L. 1
• Co-administration of an SGLT2 inhibitor may mitigate hyperkalemia risk, allowing safer MRA use. 1

Add SGLT2 Inhibitor

Initiate dapagliflozin 10mg daily or empagliflozin 10mg daily. 3, 1 SGLT2 inhibitors improve cardiovascular and renal outcomes and lower the risk of hyperkalemia in patients receiving RAAS blockade (hazard ratio ≈0.84). 1 These agents can be introduced concurrently with ACE inhibitor optimization to facilitate rapid GDMT optimization. 1

Critical Monitoring Protocol

Check blood pressure, renal function (creatinine, eGFR), and electrolytes (sodium, potassium, magnesium) 1-2 weeks after initiating or titrating any RAAS inhibitor, MRA, or diuretic change. 3, 1

• Continue monthly monitoring for the first 3 months, then every 3-6 months thereafter. 1
• Target serum potassium range is 4.0-5.0 mmol/L. 1
• Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy. 3

Medications to Avoid

Discontinue all NSAIDs immediately. 3, 1 NSAIDs promote sodium retention, worsen renal function, and blunt diuretic efficacy. 1

Avoid calcium-channel blockers with negative inotropic effects (diltiazem, verapamil). 1 These are potentially harmful in heart failure.

Do not use chronic positive inotropic agents. 1 These increase mortality and should be avoided.

Blood Pressure Targets and Titration Strategy

Target blood pressure <130/80 mm Hg while maintaining adequate perfusion. 3 However, prioritize GDMT optimization over strict blood pressure targets, as the mortality benefit from ACE inhibitors and beta-blockers persists even with lower blood pressures. 1

• If symptomatic hypotension occurs without signs/symptoms of congestion, consider reducing diuretic dose. 3
• Asymptomatic low blood pressure does not usually require any change in therapy. 3
• Reconsider need for any remaining vasodilators if dizziness, light-headedness, or confusion develops. 3

Sequencing and Timing

Titrate medications as frequently as every 1-2 weeks depending on symptoms, vital signs, and laboratory findings. 3 The goal is to reach target doses shown to be efficacious in randomized controlled trials. 3

1. Week 1: Stop HCTZ and isosorbide mononitrate; increase lisinopril to 20mg; check labs in 1-2 weeks.
2. Week 2-3: If labs stable, increase metoprolol succinate to 50mg; add SGLT2 inhibitor.
3. Week 4-6: Continue uptitrating lisinopril toward 40mg and metoprolol toward 100mg every 2 weeks as tolerated.
4. Week 6-8: Consider adding spironolactone 12.5-25mg if NYHA class III-IV and labs permit.
5. Ongoing: Continue titration every 2 weeks until target doses achieved or maximum tolerated doses reached.

Common Pitfalls to Avoid

Do not use thiazide diuretics as monotherapy when eGFR <30 mL/min (creatinine >2.0 mg/dL) because they are ineffective. 1 They can only be used synergistically with loop diuretics in this setting. 3

Do not withhold ACE inhibitors or beta-blockers solely because of CKD or modest blood pressure reductions. 1 The mortality benefit persists even with moderate renal impairment. 1

Do not combine loop diuretics and thiazides routinely without first optimizing loop diuretic dosing. 3, 2 This combination is associated with hypokalemia, hyponatremia, worsening renal function, and increased mortality. 2

Do not stop beta-blockers suddenly unless absolutely necessary. 3 There is a risk of rebound increase in myocardial ischemia/infarction and arrhythmias; ideally specialist advice should be sought before treatment discontinuation. 3

Indications for Specialist Referral

Refer to a heart-failure specialist if:

• Severe (NYHA class III-IV) heart failure persists despite optimization attempts. 1
• Intolerance to low-dose beta-blocker occurs. 1
• Relative contraindications exist (bradycardia, hypotension). 1
• Persistent hyperkalemia limits GDMT optimization. 1
• Serious deterioration occurs during medication titration. 3