Add losartan 50 mg/day and maintain both hydrochlorothiazide and metoprolol.
This patient has stage 2 HTN despite receiving two agents at normal doses. Therefore, adding losartan 50 mg/day to her existing therapy is the best option (Answer 4 is correct). The continuation of hydrochlorothiazide and metoprolol may be debated based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) versus American Heart Association (AHA) versus Canadian Hypertension Education Program (CHEP) recommendations. Nonetheless, published guidelines must be individualized to meet patient care needs on a case-by-case basis. She does not have coronary artery disease (CAD), CAD risk equivalent, diabetes mellitus, or chronic kidney disease (CKD); however, based on her angina and her father’s past MI, she is considered at risk of CAD.
Although she is tolerating both therapies well, she requires additional blood pressure control. Pharmacists should remember that about 80% of the blood pressure–lowering effects of an antihypertensive agent are seen with half-standard doses, and this patient is being treated with typical doses for each agent.
Increasing hydrochlorothiazide to 100 mg/day (Answer 1) is incorrect because it would not be expected to provide the necessary reductions in blood pressure and would likely increase her risk of metabolic adverse effects. The AHA recommendations to use low doses of thiazide diuretics apply to this patient. Increasing metoprolol tartrate to 100 mg two times/day (Answer 2) is incorrect because this dose is unlikely to be tolerated by the patient given her current pulse rate. It is also unlikely that an increase in metoprolol would provide the necessary reductions in her blood pressure. Discontinuing metoprolol and initiating losartan 50mg/day (Answer 3) is incorrect. The exchange of metoprolol 100 mg/day for losartan 50 mg/day is not expected to provide adequate target blood pressure–lowering effects.
Although AHA does not recommend the use of metoprolol as first-line therapy for primary CAD prevention, the use of two-drug therapy for this patient is unlikely to meet goals and she probably requires three-drug therapy. It is also important to assess her for causes of resistant HTN.