EYE ON THE ELDERLY—Hypertension care: Striking the proper balance
How aggressive should treatment be? Which drug combinations should raise red flags? Which drugs should you avoid entirely? Here’s how to safely customize your care.
Considerations in selecting a second agent
Patients who fail to achieve adequate blood pressure control despite lifestyle modifications and a single agent, and those who are initially diagnosed with stage 2 hypertension, will require 2 or more medications. An elderly patient who has not responded to a single agent should be asked about any other medications (or substances) that might be interfering with the antihypertensive agent, especially NSAIDs, tricyclic antidepressants, sympathomimetics, and caffeine. Find out, too, whether the patient is following the prescribed regimen.
When you prescribe 2 antihypertensives, choose agents with complementary mechanisms of action—a diuretic and an ACE inhibitor, for example, or an ACE inhibitor and a CCB. In addition to avoiding an ACE/ARB combination in patients who do not have heart failure, avoid concurrent use of beta-blockers and ACE inhibitors46 and a dihydropyridine CCB/thiazide diuretic combination47 in all elderly patients.14
How does the evidence apply to your patient?
As we saw earlier, Esther V. has isolated systolic hypertension, which increases her risk of myocardial infarction, stroke, and heart failure. Even though she is 81 years old, studies such as HYVET support the treatment of her hypertension. Certainly, you’ll encourage her to limit her salt intake, follow a healthy diet, and exercise daily, as tolerated.
But because Mrs. V. has stage 1 hypertension, her preference and her ability to tolerate therapy will play a key role in the decision to initiate treatment. If her blood pressure does not respond to lifestyle modifications and she is agreeable to medical therapy, you would recommend 1 antihypertensive agent.
Which drug class is best? Given her history of osteoporosis, a low-dose thiazide diuretic might be a reasonable choice. But because she has a history of hip fracture from a fall, it would be prudent to avoid agents associated with volume depletion —and to opt for either an ACE inhibitor or a CCB as first-line therapy instead. It is extremely important to obtain a list of any OTC medications Mrs. V. is currently taking and to advise her to avoid the use of NSAIDs.
You would also want to obtain the results of Mrs. V.’s most recent bone mineral density test, and talk to her about the importance of taking calcium with vitamin D. If there are concerns about her gait, you would consider a formal gait evaluation, as well. Finally, you would review potential side effects, including orthostatic hypotension, and tell Mrs. V. to call if they occur, and schedule an appointment to monitor her serum potassium and renal function in a few weeks.
Correspondence Robert C. Langan, MD, St. Luke’s Family Medicine Residency Program, 2830 Easton Avenue, Bethlehem, PA 18017; langanr@slhn.org
