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