Hypertension medication

I am a male 70 years of age. I have been on 150mg Irbesartan and 5mg Amlodipine daily since October 2010. This controlled by BP within acceptable limits. Since late April, however, the systolic has risen to an average of around 150. My doctor wants me to add a beta blocker to the other medications.  Since last October my heart rate was averaging below 60. Since late April it is averaging around 70. My concern is that taking both Amlodipine and a beta blocker may reduce my heart rate to an unacceptably low level.  Do you consider the adding of a beta blocker to be the best course or, instead, should I try 1) increasing the Amlodipine to 10mg daily and/or 2) adding a duretic.

[CCF HeartMD6]

Your concern is valid in that being on both a calcium channel blocker and a beta blocker can have risks of reducing the heart rate too low or affecting other conducting regions of the heart. However, amlodipine is a dihydropyridine calcium-channel blocker whose primary effect is more peripherally acting rather (as compared to the non-dihydropyridine CCB, i.e. diltiazem or verapamil, which are more centrally acting). Beta blockers is a proven medication that improves survival in those who have suffered a heart attack, have coronary artery disesase, or heart failure. If there are indications for this, then it is usually a good idea to be on one. There is no absolute value of heart rate that is too low but the general rule that is accepted is you are symptomatic, then the dose should be decreased.

Increasing the amlodipine to 10 mg is not a bad idea as you still have room to go up on it. Additionally, it's often better to increase current medicines rather than adding another agent.

A diuetic is another agent that can be used (such as hydrochlorothiazide) if there are no contraindications (renal dysfunction, elevated potassium). However, this particular agent often requires having your bloodwork checked periodically when this is started.

[warrain]

Thank you very much for your advice.

I commenced on Verapamil last year which did reduce the average heart rate to around 50 and sometimes below. Prior to that the average heart rate was mid 60's. I replaced Verapamil with Amlodipine, however, my average heart rate still stayed around 55. I found the relatively small increase surprising as I had read that verapamil wasn't supposed to have much affect on the heart rate.

I haven't suffered a heart attack, don't have diagnosed coronary artery disease or heart failure. I have periodic echocardiograms. My cholestorol is within recommended levels.

What I do have is a strong family history of hypertension with my siblings and late father (he lived to 80 with hypertension and Parkinsons) all battling to bring it under control.

The biggest disappointment to me is that, for six months, on Irbesartan and Amlodipine all was well under control and then, without known cause, the levels rose above where they should be for the last month or so.

I'm inclined to ask my Cardiologist to increase the Amlodipine to 10mg daily and see how that goes.

Thanks again.