In a patient presenting with syncope and left ventricular hypertrophy, which medication should be initiated first?

In the context of a patient presenting with syncope and left ventricular hypertrophy (LVH), the appropriate initial medication to consider is a beta-blocker, such as metoprolol. This choice is supported by the pharmacological effects of beta-blockers, which can help manage symptoms associated with LVH and improve cardiac function. They achieve this by reducing heart rate and myocardial oxygen demand, thus potentially helping to prevent further episodes of syncope that could be related to arrhythmias or decreased cardiac output.

In patients with LVH, especially those who may be symptomatic, starting a beta-blocker can also contribute to better long-term cardiovascular outcomes. Furthermore, the presence of syncope raises concern for the potential for arrhythmias, and beta-blockers are frequently utilized in such scenarios as a first-line therapy to mitigate this risk.

In comparison, while the other medications listed such as losartan (an angiotensin II receptor blocker), lisinopril (an ACE inhibitor), and hydrochlorothiazide (a thiazide diuretic) can also be beneficial in managing hypertension and LVH, they do not provide the same immediate benefit in the context of syncope or potential arrhythmias that beta-blockers do. As a result,