On Hypertension in the Elderly: An Epidemiologic Shift | Patient Case Quiz

A 78-year-old male with osteoarthritis, depression, dyslipidemia, and inferior myocardial infarction (MI) s/p right coronary artery (RCA) stenting two years ago presents to your office for initial consultation. An additional problem is that the patient has hypertension with systolic blood pressures (SBPs) in the 150-155 mm Hg range, based on home and clinic readings, despite a low-sodium diet and moderate exercise. He walks three times per week for one hour without angina or limiting dyspnea. His medications include atenolol 50 mg daily, atorvastatin 10 mg daily, and aspirin 81 mg daily. He has been compliant with his drug regimen, and he denies orthostatic dizziness or significant lower extremity edema.

Figure 1

Figure 1

On physical exam his brachial blood pressure (BP) is 150/70 mm HG on the left and 153/72 mm HG on the right, and pulse 70 beats per minute (bpm). There is no fall in BP after standing for one minute. He appears well. There is mild thinning of hair on his anterior tibial surfaces, and extremities are warm with 2+ distal pulses. His cardiac exam is notable for a soft S4 and 2/6 systolic ejection murmur at the base. Combined with normal carotid upstrokes and a normal S2, the murmur is most consistent with aortic valve sclerosis. The remainder of the exam is normal. A recent lab panel shows a normal creatinine of 0.8 mg/dL, normal electrolytes, and low-density lipoprotein cholesterol (LDL-C) of 78 mg/dL.

His electrocardiogram (ECG) (Figure 1) reveals normal sinus rhythm with a rate of 80 bpm, normal axis and intervals, and evidence of prior inferior MI, but no apparent left ventricular hypertrophy.

In addition to reinforcing a low-sodium diet and moderate exercise, which of the following is the next best step in the management of his hypertension?

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