Management of hypertension in a 65-year-old with dyslipidaemia and coronary artery disease

Definition and the importance of the problem. Hypertension is defined as a systolic blood pressure of 140 mmHg or greater and/or a diastolic blood pressure of 90 mmHg or greater. It is the major risk factor for stroke, heart failure and coronary artery disease in older adults, all of which are important contributors to mortality and functional disability. Because it is remediable and its control reduces the incidence of coronary heart disease and stroke, increased efforts at detection and treatment are indicated. In this patient, hypertension, dyslipidaemia and established coronary disease act multiplicatively, so global cardiovascular risk reduction — not blood pressure alone — is the objective.

Accurate diagnosis and measurement. Confirm with repeated measurements on at least two occasions using a validated device and correct cuff size, after 5 minutes seated rest, with the arm supported at heart level. Measure in both arms initially and use the higher reading. Always measure standing blood pressure at 1 and 3 minutes to detect orthostatic hypotension, which is common in this age group and limits how aggressively treatment can be titrated. Confirm the diagnosis with home blood pressure monitoring or 24-hour ambulatory monitoring, which also detects white-coat hypertension, masked hypertension and non-dipping. Exclude pseudohypertension from rigid calcified arteries.

Evaluation — secondary causes and target-organ damage. Screen for secondary hypertension where there is resistant or accelerated hypertension or a suggestive feature: renal parenchymal disease, renovascular disease (renal bruit, flash pulmonary oedema, AKI on ACE inhibitor), primary aldosteronism (hypokalaemia), obstructive sleep apnoea, thyroid disease, phaeochromocytoma, Cushing's syndrome, and drugs — NSAIDs, corticosteroids, decongestants, ciclosporin, erythropoietin, liquorice. Assess target-organ damage: ECG and echocardiography for left ventricular hypertrophy, urine albumin-creatinine ratio and eGFR, fundoscopy, and carotid or peripheral vascular assessment.

Baseline investigations and risk assessment. Full blood count, urea, electrolytes, creatinine and eGFR, fasting glucose and HbA1c, fasting lipid profile, uric acid, liver and thyroid function, urinalysis and ACR, ECG. Because he already has established coronary artery disease, he is by definition at very high cardiovascular risk — a risk calculator is unnecessary, and he qualifies immediately for intensive blood pressure lowering and high-intensity statin therapy.

Blood pressure targets in this patient. Aim for a systolic pressure below 130 mmHg, and generally not below 120 mmHg, with a diastolic pressure of 70–80 mmHg. In coronary artery disease, be cautious about lowering the diastolic pressure below about 70 mmHg, because coronary perfusion occurs in diastole and excessive lowering may worsen ischaemia — the "J-curve" phenomenon. Targets must be individualised: relax them in the presence of frailty, symptomatic orthostatic hypotension, falls, cognitive impairment or limited life expectancy. Standing blood pressure, not seated, should be used to guide titration in patients with postural symptoms.

Non-pharmacological management. These measures lower blood pressure and also improve lipids and glycaemia. Salt restriction to under 5 g of sodium chloride daily (an important and achievable target in the Indian diet); DASH or Mediterranean dietary pattern rich in fruit, vegetables, whole grains and low-fat dairy; weight reduction; at least 150 minutes per week of moderate aerobic exercise plus resistance training; alcohol moderation; smoking cessation; stress reduction and adequate sleep; and withdrawal of drugs that raise blood pressure, especially NSAIDs.

Choice of antihypertensive drugs — driven by the coronary disease. The comorbidity dictates the choice (a "compelling indication"):

Prescribing principles in the older adult. Start low and go slow — begin with a single low-dose agent or a low-dose combination, and review at 4-weekly intervals. Prefer adding a second low-dose drug to maximising the dose of one, and prefer single-pill combinations, which improve adherence and reduce tablet burden. Check renal function and electrolytes 1–2 weeks after starting or increasing an ACE inhibitor, ARB, diuretic or MRA. At every visit, recheck standing blood pressure, ask about dizziness and falls, and reconcile the medication list. Deprescribe or reduce doses if the patient becomes frail, loses weight, or develops symptomatic hypotension.

Concurrent management of the dyslipidaemia. With established coronary artery disease the LDL target is below 55 mg/dL (1.4 mmol/L) with at least a 50% reduction from baseline. Give a high-intensity statin (atorvastatin 40–80 mg or rosuvastatin 20–40 mg), add ezetimibe 10 mg if the target is not reached, and consider a PCSK9 inhibitor or bempedoic acid thereafter. Intensive LDL lowering has been shown to be beneficial in high-risk older patients with established cardiovascular disease. Watch for CYP3A4 interactions with amlodipine, diltiazem, verapamil and amiodarone — avoid high-dose simvastatin. Check lipids and liver function at 6–12 weeks and address statin-associated muscle symptoms promptly rather than allowing silent discontinuation.

Complete the secondary prevention package and follow up. Add aspirin 75 mg daily (secondary prevention — established coronary disease), sublingual GTN for angina with clear instructions, and consider an SGLT2 inhibitor or GLP-1 receptor agonist if diabetes coexists. Arrange cardiac rehabilitation, influenza, pneumococcal and COVID-19 vaccination, and screening for and treatment of obstructive sleep apnoea, depression and anaemia. Follow up monthly until controlled, then 3–6 monthly, with annual renal function, electrolytes, lipids and ECG. Reinforce adherence at every visit — non-adherence is the commonest cause of apparent resistant hypertension. Add Indian context: high dietary salt, low potassium intake, early-onset and more aggressive ASCVD, and a large treatment gap — API and Lipid Association of India consensus recommend intensive risk factor control in this group.

2025 AHA/ACC multisociety High Blood Pressure Guideline — the first major US update since 2017, and co-authored by the American Geriatrics Society. Key changes: a universal treatment target of below 130/80 mmHg with further encouragement to reach a systolic pressure below 120 mmHg, supported by SPRINT, STEP (which specifically randomised patients aged 60–80), ESPRIT and BPROAD; replacement of the Pooled Cohort Equations with the PREVENT risk calculator; a strong endorsement of single-pill combination therapy and of out-of-office (home or ambulatory) measurement for both diagnosis and titration; a new Class IIb recommendation for renal denervation in uncontrolled hypertension; and explicit individualised exceptions to the target for institutionalised patients, those with limited life expectancy and the frail.

2024 ESC Guidelines for Elevated Blood Pressure and Hypertension introduced a new intermediate category of "Elevated BP" (systolic 120–139 or diastolic 70–89 mmHg), in which treatment is considered for those at high cardiovascular risk, and set a general on-treatment target of systolic 120–129 mmHg where tolerated. Crucially for geriatric practice, the guideline recommends that treatment be guided by tolerability rather than by chronological age, mandates routine screening for orthostatic hypotension, and applies a less intensive, symptom-guided target in patients with significant frailty or limited life expectancy.