Uncontrolled Hypertension in an Elderly Man on Multiple Antihypertensive Drugs

We present a case of uncontrolled hypertension in an 80-year-old White male and retired family medicine physician despite being on multiple antihypertensive drugs. The patient was a nonsmoker, nondiabetic, and had a past medical history of hypertension for 25 years, coronary artery disease with stenting 2 years before presentation, bioprosthetic aortic valve replacement for aortic stenosis, paroxysmal atrial fbrillation with a history of transient ischemic attack on clopidogrel and aspirin, chronic lymphocytic leukemia with bulky lymphadenopathy and normal leukocyte count on ibrutinib, benign prostatic hypertrophy, hyperlipidemia, and chronic kidney disease, stage 3 with a baseline creatinine of 1.3 mg/dL. His blood pressure (BP) was previously well controlled for many years on monotherapy, initially with atenolol and later with amlodipine. In 2015, he developed acute kidney injury with a peak creatinine of 2.5 mg/dL in the setting of sepsis due to aspergillosis. Amlodipine was stopped during that episode. His kidney function eventually recovered to baseline. He was then placed on lifelong posaconazole prophylaxis. BP was controlled with lifestyle factors only over the next 2 years until 2017 after which home and clinic readings began ranging from 130 to 180/60 to 80 mmHg with headaches associated with higher readings. For the worsening hypertension, he was treated with an escalating antihypertensive drug regimen. He was initiated on losartan 50 mg daily, and then metoprolol tartrate 25 mg twice daily was added. Initially, BP control improved, and then 3 months before our evaluation the hypertension worsened with more frequent headaches. HCTZ (hydrochlorothiazide) 25 mg daily and amlodipine 2.5 mg daily were added. Subsequently, the patient developed lower extremity edema. He was prescribed furosemide 40 mg daily as needed, and he reported taking it twice weekly. BP remained uncontrolled, and we were consulted for further management. Upon evaluation in our clinic, the patient had no new concerns other than what was previously mentioned. Home BP readings were reviewed and were consistent with prior reports of suboptimal control. Average offce BP using the BPTru device was 144/77 mmHg. BPs were equal in both arms. A standing BP was also elevated at 142/74 mmHg. Pulse was 62 beats per minute, and body mass index was 28 kg/m2 with a weight of 70 kg, which had been stable over the previous 2 years. On physical exam, he was alert and appeared younger than stated age. He had a benign funduscopic exam. His cardiac exam revealed a low-grade systolic murmur over the aortic area, and he had a signifcant amount of pitting edema in both lower extremities as well as the right upper extremity some of which was chronic in the setting of chronic lymphocytic leukemia and associated bulky lymphadenopathy and lymphedema. His lungs were clear except for chronic changes in the right lung base from the prior pneumonia from aspergillosis. His abdomen was soft with no bruits, masses, or organomegaly, and his pulses were normal. After being presented with this information, what are the initial thoughts and considerations in this patient with uncontrolled hypertension?.