Addition of the ACE inhibitor lisinopril is appropriate. This 60-year-old patient has stage 1 hypertension. The eighth report of the Joint National Committee (JNC 8) recommends a treatment goal of <150/90 mm Hg for patients with hypertension who are ≥60 years. Given her age and no evidence of cardiovascular or kidney disease and lack of frailty, this patient's treatment goal according to JNC 8 is <150/90 mm Hg. In her circumstance, given a longer expected lifetime than the general population for this age, cautious stepped care for lower blood pressure goals is reasonable. Increasing the dose of one agent is less effective in reducing blood pressure than the addition of a second agent at low dose, which also avoids the risk of side effects more commonly seen at higher doses. In this case, the minor pedal edema may be exacerbated by increasing the amlodipine.

In the absence of any indications for β-blocker therapy (tachycardia, history of angina, or a recent myocardial infarction), metoprolol is not indicated for the initial therapy of hypertension. It can be considered as add-on therapy typically in the setting of vasodilator-induced tachycardia, but given the low resting pulse rate in this patient, an alternative agent should be considered. The Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial demonstrated the benefit of combination therapy with a calcium channel blocker and an ACE inhibitor in reducing cardiovascular events compared with combination therapy using a thiazide diuretic and an ACE inhibitor.

In a 2017 guideline, the American College of Physicians and American Academy of Family Physicians addressed the treatment of hypertension in patients ≥60 years of age (Qaseem et al, 2017). The guideline includes three recommendations:

• Initiate treatment in patients ≥60 years of age with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events.
• Consider initiating or intensifying pharmacologic treatment in patients ≥60 years of age with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke.
• Consider initiating or intensifying pharmacologic treatment in some patients ≥60 years of age at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events.