39
CHAPTER 7
FIGURE 6-2. Electrocardiogram showing torsades de pointes.
7
HYPERTENSION
FIGURE 6-3. The Heartstart Home Defibrillator, an automated external
defibrillator (AED) device approved by the FDA for home use. (Photograph courtesy of Philips Medical Systems, Bothell, Washington.)
Salty Sam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level II
Julie M. Koehler, PharmD
James E. Tisdale, PharmD, BCPS, FCCP
Outcome Evaluation
5. How should the patient be monitored to assess drug efficacy and
to prevent or detect adverse effects? Describe how the therapy
should be adjusted if adverse events occur.
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
■ SELF-STUDY ASSIGNMENTS
•
1. Search the Internet for commercially available automated external defibrillator (AED) devices (see Fig. 6-3 for one example). Explain how such a device would be used by a layperson during a
cardiac arrest that occurred in the home or workplace.
Classify blood pressure according to JNC 7 Guidelines, and discuss the correlation between blood pressure and risk for cardiovascular morbidity and mortality.
•
Identify medications that may cause or worsen hypertension.
•
Discuss complications (e.g., target organ damage, clinical cardiovascular disease) that may occur as a result of uncontrolled and/
or long-standing hypertension and identify cardiovascular risk
factors.
2. Perform a literature search to determine the odds of surviving a
cardiac arrest while hospitalized.
3. List medications that can be administered through an endotracheal tube in an emergent situation.
CLINICAL PEARL
During a cardiac arrest, a patient’s serum potassium will increase
dramatically due to the presence of metabolic acidosis; this can
worsen or complicate arrhythmia conversion.
REFERENCES
1. Hazinski MF, Chameides L, Elling B, et al. (eds). 2005 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24):Suppl IV.
2. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the
prevention of sudden cardiac death: a report of the American College
• Establish goals for the treatment of hypertension, and choose
appropriate lifestyle modifications and antihypertensive regimens based on patient-specific characteristics and co-morbid
disease states.
•
Provide appropriate patient counseling for antihypertensive
drug regimens.
PATIENT PRESENTATION
쐽 Chief Complaint
“I just moved to town, and I’m here to see my new doctor for a checkup. I’m just getting over a cold. Overall, I’m feeling fine, except for
occasional headaches and some dizziness in the morning. My other
doctor prescribed a low-salt diet for me, but I don’t like it!”
Hypertension
of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients
With Ventricular Arrhythmias and the Prevention of Sudden Cardiac
Death). Circulation 2006;114:e385–e484.
3. Wenzel V, Krismer AC, Arntz HR, et al. A comparison of vasopressin
and epinephrine for out-of-hospital cardiopulmonary resuscitation. N
Engl J Med 2004;350:105–113.
40
SECTION 2
쐽 HPI
HEENT
Sam Street is a 62-year-old African-American male who presents to
his new family medicine physician for evaluation and follow-up of his
medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning
medications. He states that he is dissatisfied with being placed on a
low sodium diet by his former primary care physician. He reports a
“usual” chronic cough and shortness of breath, particularly when
walking moderate distances (states, “I’m just out of shape”).
TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages,
exudates, or papilledema
Cardiovascular Disorders
쐽 PMH
Hypertension × 15 years
Type 1 diabetes mellitus
Chronic obstructive pulmonary disease, Stage 2 (Moderate)
Benign prostatic hyperplasia
Chronic kidney disease
쐽 FH
Father died of acute MI at age 71. Mother died of lung cancer at age
64. Mother had both HTN and DM.
쐽 SH
Former smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports
moderate amount of alcohol intake. He admits he has been nonadherent to his low sodium diet (states, “I eat whatever I want.”) He
does not exercise regularly and is limited somewhat functionally by
his COPD. He is retired and lives alone.
쐽 Meds
Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM
Insulin 70/30, 24 units Q AM, 12 units Q PM
Doxazosin 2 mg po Q AM
Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath
Tiotropium DPI 18 mcg 1 capsule INH daily
Salmeterol DPI 1 INH BID
Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms
Acetaminophen 325 mg po Q 6 h PRN headache
쐽 All
PCN—Rash
쐽 ROS
Patient states that overall he is doing well and just getting over a
cold. He has noticed no major weight changes over the past few
years. He complains of occasional headaches, which are usually
relieved by acetaminophen, and he denies blurred vision and chest
pain. He states that his shortness of breath is “usual” for him, and
that his albuterol helps. He denies experiencing any hemoptysis or
epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary
frequency, but states that he used to have difficulty urinating until
his physician started him on doxazosin a few months ago.
Neck
Supple without masses or bruits, no thyroid enlargement or lymphadenopathy
Lungs
Lung fields CTA bilaterally. Few basilar crackles, mild expiratory
wheezing
Heart
RRR; normal S1 and S2. No S3 or S4
Abd
Soft, NTND; no masses, bruits, or organomegaly. Normal BS.
Genit/Rect
Enlarged prostate; benign
Ext
No CCE
Neuro
No gross motor-sensory deficits present. CN II–XII intact. A & O × 3.
쐽 Labs
Na 142 mEq/L
K 4.8 mEq/L
Cl 101 mEq/L
CO2 27 mEq/L
BUN 22 mg/dL
SCr 1.6 mg/dL
Glucose 136
mg/dL
Ca 9.7 mg/dL
Mg 2.3 mEq/L
HbA1C 6.2%
Alb 3.5 g/dL
Hgb 13 g/dL
Hct 40%
WBC 9.0 × 103/mm3
Plts 189 × 103/mm3
Fasting Lipid
Panel
Total Chol 169
mg/dL
LDL 99 mg/dL
HDL 40 mg/dL
TG 151 mg/dL
Spirometry
(6 months ago)
FVC 2.38 L
(54% pred)
FEV1 1.21 L
(38% pred)
FEV1/FVC 51%
쐽 UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–)
ketones, (–) bilirubin, (–) blood, (–) nitrite, RBC 0/hpf, WBC 1–2/
hpf, neg bacteria, 1–5 epithelial cells
쐽 ECG
Normal sinus rhythm
쐽 ECHO (6 months ago)
Mild LVH, estimated EF 45%
쐽 Assessment
1. Hypertension, uncontrolled
2. Type 1 diabetes mellitus, controlled on current insulin regimen
3. Moderate COPD, stable on current regimen
4. BPH, symptoms improved on doxazosin
쐽 Physical Examination
Gen
WDWN, African-American male; moderately overweight; in no
acute distress
VS
BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular),
RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2''
QUESTIONS
Problem Identification
1.a. Create a list of this patient’s drug-related problems, including
any medications which may be contributing to the patient’s
uncontrolled hypertension.
41
CHAPTER 7
1.b. How would you classify this patient’s HTN (e.g., Prehypertension, Stage 1, or Stage 2), according to JNC 7 Guidelines?
1.c. What are the patient’s known cardiovascular risk factors, and
what is the patient’s Framingham risk score?
1.d. What evidence of target organ damage or clinical cardiovascular
disease does this patient have?
Desired Outcome
Hypertension
2. List the goals of treatment for this patient (including the patient’s
goal blood pressure, according to JNC 7 Guidelines).
Therapeutic Alternatives
3.a. What lifestyle modifications should be encouraged for this
patient to achieve and maintain adequate blood pressure
reduction?
3.b. What reasonable pharmacotherapeutic options are available
for controlling this patient’s blood pressure, and what comorbidities and individual patient considerations should be
taken into account when selecting pharmacologic therapy for
his HTN? How might Mr. Street’s HTN medications potentially affect his other medical problems?
Optimal Plan
FIGURE 7-1. The LifeSource UA-767 Plus—One-Step Plus Memory digital home blood pressure monitor. (Photo courtesy of A&D Medical,
Milpitas, California.)
• Renovascular disease (bilateral or unilateral renal artery
stenosis)
• Heart failure due to left ventricular systolic dysfunction
3. Describe how you would explain to a patient how to use a
digital home blood pressure monitor such as the one shown in
Fig. 7-1.
4.a. Outline specific lifestyle modifications for this patient.
4.b. Outline a specific and appropriate pharmacotherapeutic regimen
for this patient’s uncontrolled hypertension, including drug(s),
dose(s), dosage form(s), and schedule(s).
Outcome Evaluation
5. Based on your recommendations, what parameters should be
monitored after initiating this regimen and throughout the
treatment course? At what time intervals should these parameters
be monitored?
Patient Education
6. Based on your recommendations, provide appropriate education
to this patient.
■ SELF-STUDY ASSIGNMENTS
1. Review the American Heart Association Scientific Statement on
the treatment of hypertension in the prevention of and management of ischemic heart disease, and highlight the key differences
in recommendations for managing a hypertensive patient with
known CHD.
2. Outline the changes, if any, that you would make to the pharmacotherapeutic regimen for this patient if he had a history of each
of the following co-morbidities or characteristics:
• Severe-persistent asthma
• Major depression
• Gout
• Cerebrovascular disease
• Peripheral arterial disease
• Isolated systolic hypertension
• Migraine headache disorder
• Liver disease
CLINICAL PEARL
The risk of hemorrhagic stroke may be increased by the use of
aspirin therapy in patients with uncontrolled hypertension.
REFERENCES
1. Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine
on blood pressure and heart rate: a meta-analysis. Arch Intern Med
2005;165:1686–1694.
2. Chobanian AV, Bakris GL, Black HR, et al. and the National High
Blood Pressure Education Program Coordinating Committee. Seventh
report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Hypertension
2003;42:1206–1252.
3. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension
in the prevention and management of ischemic heart disease: a
scientific statement from the American Heart Association Council for
High Blood Pressure Research and the Councils on Clinical Cardiology
and Epidemiology and Prevention. Circulation 2007;115:2761–2788.
4. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of
reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N
Engl J Med 2001;344:3–10.
5. Douglas JG, Bakris GL, Epstein M, et al. Management of high blood
pressure in African Americans: Consensus Statement of the Hypertension in African Americans Working Group of the International Society
on Hypertension in Blacks. Arch Intern Med 2003;163:525–541.
6. ALLHAT Officers and Coordinators for the ALLHAT Collaborative
Research Group. Major outcomes in high-risk hypertensive patients
randomized to angiotensin-converting enzyme inhibitor or calcium
channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA
2002;288:2981–2997.
7. UKPDS 39. Efficacy of atenolol and captopril in reducing risk of
macrovascular and microvascular complications in type 2 diabetes:
UKPDS 39. UK Prospective Diabetes Study Group. BMJ 1998;317:713–
720.