In the management of hypertension in a patient with chronic kidney disease and ASCVD, which medication adjustment is most appropriate?

In managing hypertension in patients with chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD), it is crucial to achieve optimal blood pressure control to reduce the risk of cardiovascular events and further kidney damage. The addition of an additional antihypertensive agent is often necessary when a patient's blood pressure remains above target levels despite being on an existing regimen.

Patients with CKD may experience altered pharmacokinetics and dynamics, necessitating careful consideration of their antihypertensive therapy. The use of a combination of agents can provide a synergistic effect, improving overall blood pressure control and potentially offering renal protection. This strategy is particularly important when dealing with resistant hypertension or when the patient is not reaching target blood pressure goals.

In contrast, increasing the dose of metoprolol may not adequately address the hypertension unless the beta-blocker is not maximal therapy, and simply adding another agent may yield better results. Lowering the dosage of lisinopril is counterproductive, as ACE inhibitors are beneficial for renal protection in CKD and should typically be continued or optimized rather than decreased. Switching to a non-dihydropyridine calcium channel blocker may not address the underlying issues as effectively and may also complicate the management of the