Case
70-year-old asymptomatic man with hypertension but not cardiovascular disease presented for a routine check. His pulse rate was 40bpm. His son, aged 45, recently had an MI in Australia.
His medications include
- Doxazosin 8mg OD
- Metoprolol 95mg CR OD – since 2006
- Cilazapril 5mg / Hydrochlorothiazide 12.5mg OD
ECG shows sinus bradycardia, with normal PR interval, QRS duration.
Discussion
Without proven cardiovascular disease, in particular, angina and/or heart failure, the role of beta-blockers for hypertension is debatable. Even though he is asymptomatic from the sinus bradycardia, it would be useful to adjust his medications with less beta-blockade, and introduce calcium channel blocker.
First line agents for hypertension are one of three classes:
- ACE inhibitors or Angiotensin receptor blockers
- Thiazides
- Calcium channel blockers
There may be some advantage of using ACEi/ARB in the young vs. CCB/thiazides in the older population where isolated systolic hypertension is more prevalent.
β-blocker is generally NOT preferred as first line agent. (JNC8) The exceptions are in the settings of post-myocardial infarction, and heart failure.
Drug preference is mainly influenced by co-morbidities and contraindications, rather than a simple age cut-off.
Author: Dr Andrew To