Orthostatic Hypotension in Elderly — EECC MCQ

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EasyGeneral CardiologyOrthostatic Hypotension in ElderlyEECC

A 72-year-old woman with HFpEF, AF, and hypertension is found to have a resting heart rate of 55 bpm on bisoprolol 5 mg daily. She feels dizzy on standing. Her lying BP is 148/82 mmHg and standing BP is 108/60 mmHg at 3 minutes. What is the most appropriate medication adjustment?

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Correct answer: E — Reduce bisoprolol because of symptomatic bradycardia

This elderly patient has symptomatic orthostatic hypotension (≥20 mmHg systolic drop) and relative bradycardia (HR 55 bpm) on bisoprolol, which is the likely culprit. In elderly patients with HFpEF, over-aggressive rate and blood pressure lowering can cause more harm than benefit. The 2024 ESC Hypertension Guidelines emphasise the importance of checking standing BP in elderly patients and adjusting treatment to avoid orthostatic symptoms. The bisoprolol dose should be reduced (or switched to a less bradycardia-inducing agent). Adding agents to treat the side effects of another drug (polypharmacy cascade) should be avoided when the simpler solution is dose adjustment. Apply this conclusion only to the clinical circumstances stated, with appropriate specialist review, contraindication checks, shared decision-making and follow-up. Reassess if the physiology, treatment response or competing risk changes. The competing options would require a different haemodynamic profile, diagnosis, procedural indication or risk balance from the one described here.

Reference: ESC (2024): Guidelines for Hypertension; ESC (2023): HF Guidelines: https://bnf.nice.org.uk/