In an 87‑year‑old woman with hypotension while taking amlodipine 2.5 mg daily, lisinopril 30 mg daily, and metoprolol 50 mg daily, how should her antihypertensive regimen be adjusted?

Management of Hypotension in an 87-Year-Old Woman on Triple Antihypertensive Therapy

In this 87-year-old woman experiencing hypotension on amlodipine 2.5 mg, lisinopril 30 mg, and metoprolol 50 mg daily, discontinue or significantly reduce the metoprolol first, as beta-blockers are the least essential agent in this regimen and most likely to cause symptomatic hypotension in elderly patients without compelling cardiac indications. 1

Immediate Assessment Priorities

• Confirm true hypotension by obtaining multiple blood pressure readings at different times of day, as single low readings may reflect peak drug effect, postural changes, or measurement error rather than sustained hypotension. 1
• Measure blood pressure in both sitting and standing positions to detect orthostatic hypotension, which occurs frequently in patients ≥85 years and is exacerbated by polypharmacy. 1
• Avoid systolic pressures <110 mmHg and diastolic pressures <60 mmHg, as excessive lowering increases risk in elderly patients, particularly those with coronary artery disease. 1

Stepwise Medication Adjustment Algorithm

Step 1: Discontinue or Reduce Metoprolol (First Priority)

• Beta-blockers should not be used as first-, second-, or third-line agents unless compelling indications exist (heart failure with reduced ejection fraction, recent myocardial infarction, angina, or atrial fibrillation requiring rate control). 1
• Beta-blockers are less effective than calcium channel blockers or diuretics for stroke prevention and cardiovascular event reduction in elderly patients with uncomplicated hypertension. 2, 1
• In the absence of a documented cardiac indication, metoprolol 50 mg daily should be discontinued entirely rather than dose-reduced. 1
• If a compelling cardiac indication exists, reduce metoprolol to 25 mg daily and reassess blood pressure within 1–2 weeks. 1

Step 2: Reduce Lisinopril Dose (Second Priority if Hypotension Persists)

• Lisinopril 30 mg daily exceeds the typical maintenance dose for most elderly patients; the FDA-approved usual dosage range is 20–40 mg daily, with doses up to 80 mg studied but not providing greater effect. 3
• Reduce lisinopril from 30 mg to 20 mg daily if blood pressure remains low after metoprolol discontinuation. 1, 3
• ACE inhibitors provide renal protection and cardiovascular event reduction, making them preferable to retain over beta-blockers in elderly patients. 1
• Check serum creatinine and potassium 1–2 weeks after dose reduction, as a rise in creatinine up to 20% is acceptable and does not indicate progressive renal damage. 1

Step 3: Maintain Amlodipine 2.5 mg (Lowest Priority for Reduction)

• Amlodipine 2.5 mg once daily is the recommended starting dose in elderly patients and should be maintained unless hypotension persists after adjusting the other two agents. 2, 1
• Dihydropyridine calcium channel blockers do not cause bradycardia, are well-tolerated in elderly patients, and provide superior stroke prevention compared with beta-blockers. 2, 1
• Amlodipine demonstrates equivalent or superior blood pressure reductions in elderly patients (age ≥65 years) with good tolerability, achieving reductions of 25/16 mmHg in patients ≥65 years and 26/17 mmHg in those ≥75 years. 4, 5
• Only reduce amlodipine to 2.5 mg every other day or discontinue entirely if symptomatic hypotension continues despite metoprolol discontinuation and lisinopril dose reduction. 1

Blood Pressure Targets for Patients ≥85 Years

• For functionally independent adults ≥85 years, initiate or maintain antihypertensive therapy when systolic ≥140 mmHg or diastolic ≥90 mmHg, with a primary target of 120–129 mmHg systolic if tolerated. 1
• The minimum acceptable target is <140/90 mmHg; if the intensive target is poorly tolerated, apply the "as-low-as-reasonably-achievable" principle. 1
• Blood pressure-lowering treatment should be continued lifelong in older adults, including beyond age 85, as long as it is tolerated; discontinuation increases cardiovascular risk. 1
• Do not withhold treatment solely on the basis of chronological age; decisions should be guided by functional status and frailty. 1

Monitoring After Medication Adjustment

• Re-measure blood pressure 1–2 weeks after discontinuing metoprolol to assess response and determine whether further dose reductions are needed. 1
• If blood pressure rises to ≥140/90 mmHg after metoprolol discontinuation, consider adding a thiazide-like diuretic (chlorthalidone 12.5 mg daily) rather than restarting metoprolol. 2, 1
• Thiazide-like diuretics are preferred over beta-blockers as third-line agents in elderly patients without heart failure or recent myocardial infarction. 2, 1

Special Considerations in Frail or Very Elderly Patients

• For patients ≥85 years with moderate-to-severe frailty, begin with monotherapy (preferably a dihydropyridine calcium channel blocker) rather than combination therapy to limit adverse effects. 1
• When symptomatic orthostatic hypotension is present, reconsider the use of combination therapy and adopt a more cautious approach. 1
• Gradual dose escalation is mandatory in the very elderly—high initial doses raise the risk of hypotension, falls, and treatment discontinuation. 1

Common Pitfalls to Avoid

• Do not continue beta-blocker therapy in elderly patients without a documented compelling cardiac indication, as this exposes them to unnecessary bradycardia, fatigue, and hypotension. 1
• Do not reduce all three medications simultaneously, as this may cause rebound hypertension; adjust one agent at a time with 1–2 week intervals for reassessment. 1
• Do not assume low blood pressure readings reflect true sustained hypotension without confirming with multiple measurements, including home blood pressure monitoring. 1
• Do not delay dose adjustment when symptomatic hypotension is documented, as prolonged hypotension increases fall risk and may precipitate syncope in elderly patients. 1

Alternative Regimen if Blood Pressure Becomes Uncontrolled

• If blood pressure rises to ≥160/90 mmHg after metoprolol discontinuation, add chlorthalidone 12.5 mg once daily in the morning rather than restarting metoprolol. 2, 1
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration of action (24–72 hours vs. 6–12 hours) and superior cardiovascular outcome data. 1
• Monitor serum potassium and creatinine 2–4 weeks after initiating chlorthalidone to detect hypokalemia or renal function changes. 1