Cardiovascular Disorders
Hypertension
Treating hypertension in older adults reduces stroke and heart failure. Guidelines favor a target below 130/80 for community-dwelling ambulatory patients who tolerate it, with individualized goals in frailty or limited life expectancy. Start low, go slow. Thiazide-type diuretics, dihydropyridine calcium channel blockers, and ACE inhibitors or ARBs are first-line. Watch for orthostatic hypotension - check blood pressure standing after one and three minutes - and for electrolyte disturbance with thiazides and hyperkalemia with ACE inhibitors, ARBs, and potassium-sparing agents.
Heart Failure
Know reduced versus preserved ejection fraction. For HFrEF, guideline-directed therapy includes an ARNI or ACE inhibitor/ARB, evidence-based beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor; sacubitril/valsartan requires a 36-hour washout from ACE inhibitors to avoid angioedema. In HFpEF, SGLT2 inhibitors have outcome data. Diuretics relieve congestion but do not change mortality. In older adults, watch for hypotension, worsening renal function, and hyperkalemia when layering agents.
Atrial Fibrillation and Anticoagulation
Use CHA2DS2-VASc for stroke risk and HAS-BLED to flag modifiable bleeding risk, not to withhold anticoagulation. Direct oral anticoagulants are preferred for most nonvalvular AF; dose reductions must follow label criteria (age, weight, creatinine clearance), and underdosing is a common error. Warfarin remains appropriate for mechanical valves and moderate-to-severe mitral stenosis.
Traps
Questions conflate rate with rhythm control indications, forget the washout, or apply DOAC dose reductions without meeting all criteria. Orthostatic vitals are often omitted in stems describing falls.
Rule of Thumb
Before adding an antihypertensive to a patient who reports dizziness, measure standing blood pressure; if it drops more than 20 mmHg systolic or 10 mmHg diastolic, address the regimen rather than the reading.