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Case studies in
+ Learning Objectives
 Classify blood pressure according to current hypertension
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) that may occur

as a result of uncontrolled and/or long-standing hypertension, and
identify additional cardiovascular risk factors.

 Establish goals for the treatment of hypertension, and choose

appropriate lifestyle modifications and antihypertensive regimens
based on patient-specific characteristics and comorbid disease

 Provide appropriate patient counseling for antihypertensive drug

+ Patient Presentation

Chief Complaint
“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!”
+ History of present illness
 James Frank is a 64-year-old African-American
man 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.
+ Past medical history
 Hypertension (HTN) × 14 years

 Type 2 diabetes mellitus × 16 years

 Chronic obstructive pulmonary disease (COPD), GOLD 3/Group C

 Benign prostatic hyperplasia

 Chronic kidney disease

 Gout

Family history
Father died of acute MI at age 73. Mother died of lung
cancer at age 65. Father had HTN and dyslipidemia. Mother
had HTN and diabetes mellitus.
+ Social History
 Former smoker (quit 6 years ago; 35 pack-year history);
reports moderate amount of alcohol intake. He admits
he has been non adherent 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.
+ Medications
 Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q am

 Insulin glargine 36 units subcutaneously daily

 Insulin lispro 12 units subcutaneously TID with meals

 Doxazosin 2 mg po Q am (BPH)

 Carvedilol 12.5 mg po BID

 Albuterol HFA MDI, two inhalations Q 4–6 h PRN shortness of breath

 Tiotropium DPI 18 mcg, one capsule inhaled daily

 Fluticasone/salmeterol DPI 250/50, one inhalation BID

 Mucinex D two tablets Q 12 h PRN cough/congestion

 Naproxen 220 mg po Q 8 h PRN pain/HA

 Allopurinol 200 mg po daily (gout)

+ Review of system
 Patient states that overall he is doing well and recovering
from a cold. He has noticed no major weight changes over
the past few years. He complains of occasional headaches,
which are usually relieved by naproxen, and he denies
blurred vision and chest pain. He states that shortness of
breath is “usual” for him, and that his albuterol helps. He
reports having had two COPD exacerbations within the past
12 months. 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. He has no prior history of
arthritic symptoms and states that his occasional gout pain
is also relieved with naproxen.
+ Physical Examination
 Well
developed/well nourished, African-American
male; moderately overweight; in no acute distress .

Vital sign
 BP162/90 mm Hg (sitting; repeat 164/92 mm Hg),
HR 76 bpm (regular), Respiratory rate 16/min, T
37°C; Wt 95 kg, Ht 6′2″

Head, eyes, ears, nose and throat

 Tympanic membrane clear; mild sinus drainage;
atrioventricular nicking noted; no hemorrhages,
exudates, or papilledema
+ Neck
 Supplewithout masses or bruits, no thyroid
enlargement or lymphadenopathy

 Lung fields clear of Auscultation bilaterally. Few
basilar crackles, mild expiratory wheezing.

 Regular rate and rhythm; normal S1 and S2. No S3 or S4.

 Soft,
NTND; no masses, bruits, or organomegaly.
Normal Bowel sounds.
+ Genit/Rect
 Enlarged prostate

 No CCE; no apparent joint swelling or signs of tophi

 No gross motor-sensory deficits present. CN II–XII
intact. A & O × 3. alert and oriented to place , time
and person.
+ Labs
Urine Analysis
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

Normal sinus rhythm

ECHO (6 Months Ago)

Mild left ventricular hypertrophy, estimate ejection
fraction 45%
+ Assessment
• HTN, uncontrolled
• Type 2 diabetes mellitus, controlled on current insulin
• COPD, stable on current regimen
• BPH, symptoms improved on Doxazosin
• Gout, controlled on current regimen

Clinical Pearls
The risk of hemorrhagic stroke may be increased by the use
of aspirin therapy in patients with uncontrolled HTN (e.g., BP
>150/90 mm Hg).
The majority of hypertensive patients will require two or more
blood pressuring–lowering medications to achieve
recommended blood pressure goals.
+ Questions

 It’spreferable to calculate the CrCl and corrected

calcium for patient with HTN.
 CrCL=45.58ml/min

He use thiazide that works on CrCl >30ml/min .

Depend on sex, age, weight and SCr.
 Corrected Ca +2 = 10.18mg/dl so it’s normal no need
for the supplement.
Depend on SCr and Albumin.
 Note : the used equations can be found online.
Lab test analysis:

 His
serum creatinine is high 2.2mg/dl and
normal range for male is (0.7-1.3mg/dl).
 He has proteinuria.
 His BP is uncontrolled.
+ Questions
Problem Identification
1.a. Create a list of this patient’s drug-related
problems, including any medications that may
be contributing to his uncontrolled HTN.
• Drug Adverse effect:

Doxazosin causing dizziness.

Mucinex D (pseudoephedrine, Guafinacin) decongestant may increase the blood


• Drug choice problem:

Elderly 64yrs, HTN, DM-type 2 and African American in this case ACE inhibitors or
ARBs are more efficient. (The drug of choice).

• The patient is non adherent to low sodium intake .

+  Drug-drug interactions:
{D} Doxazosin α blocker / Carvedilol (non selective β
blockers …... Dose must be adjusted with β blockers or
choose more selective β blocker.

{C} Naproxen (NSAID)/ Carvedilol…… causing sodium

and water retention so may increase the blood

{X} Albuterol β2 agonist / Carvedilol …... Can’t be used


{X} Fluticasone-salmeterol /Carvedilol …... Can’t be

used together.

These are the highly strong drug-drug interactions .

1.b. How would you classify this
patient’s HTN, according to
current HTN guidelines?

We are in the treatment phase so

BP or HTN can be described as :
Uncontrolled HTN/stage 2.
1.c.What are the patient’s known
cardiovascular risk factors, and
what is his Framingham risk
HTN, smoking, physical inactivity, DM, kidney disease,
age>55 and family history of CVD.
The Framingham risk score = 24%.
This score defined as : 10 yrs risk of getting CVD.
For our patient , there is no need to calculate the score,
because he has history of MI so the risk is already >
20% high value.
+ 
1.d. What evidence of target
organ damage or clinical
cardiovascular disease does
this patient have?
He has CKD and has high risk to get MI as his
mother. So both the kidney and the heart will be
Kidney…… CKD, proteinuria.
Eyes…..AV nicking.
+ Desired Outcome
2. List the goals of treatment for
this patient (including his goal
blood pressure).
Goal blood pressure = <140/90 according to JNC
Wt (BMI) = 18.5-24.9 kg/m2
Na daily intake <100 mmol/day.
According to ADA BP=<140/80
According to KDIGO CKD with proteinuria BP <=
+ Therapeutic Alternatives
3.a. What lifestyle modifications should
be encouraged for this patient to help
achieve and maintain adequate blood
pressure reduction?

Wt loss (BMI) = 18.5-24.9 kg/m2

Dash diet : high fruits, vegetables intake, low fat intake and
high potassium intake.
Physical activity : FITT at least 30 min/day.
No smoking or stress.
Moderate alcohol intake.
+ 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 Frank’s HTN
medications potentially affect his other
medical problems?
ACE inhibitors or ARBs are the best because of decreasing
Old age >60 , CKD (ACE-I or ARBs), HTN, DM-type2 (β
blockers - mask hypoglycemia) and black (CCB or thiazides).
We weigh benefits Vs. risk and then choose the best therapy.
+ Optimal Plan

4.a. Recommend specific lifestyle

modifications for this patient.
+ 4.b. Outline a specific and appropriate
pharmacotherapeutic regimen for this
patient’s uncontrolled HTN, including
drug(s), dose(s), dosage form(s), and

ACE inhibitor or ARB…….. If goal is not reached then …… CCBs or

thiazides ……..if goal is not achieved then ……. β blockers can be
This term can be followed by three strategies A,B,C but C is the most
preferable to start with a combination therapy composed of two drugs.
(lisinopril 10-40 mg/day, taken once daily) or Candesartan 8-
32mg/day taken once or twice daily)………… Amlodipine (2.5-
10mg/day, taken once daily) or hydrochlorothiazide (12.5-
25mg/day, taken once or twice daily)………….Atenolol (25-
100mg/day, taken once daily).
+ 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?

• Mainly potassium because of hyperkalemia and

measured every week.
• BP also to check if reach the goal or not every 2-4
• Adverse effect of ACE-I cough and angioedema. If
necessary stop the medication or change it with ARBs
which is much expensive.
• Na+, glucose and uric acid every 2-4 weeks.
+Patient Education
6. Based on your recommendations, provide
appropriate education to this patient.
 The patient is not adherent to the diet and lower salt intake, so the physician must
show the patient the predictable outcomes from following the treatment regimen.

 The patient must be aware that ACE-I cause cough and angioedema. If cough is
severe we can switch to ARBs and if Angioedema occur then ACE-I will become
contraindicated and must use ARBs.

 The patient must be aware that Doxazosin causes dizziness, so we can advice the
patient to take the drug at night to avoid this.

 It’s important to take the drug on time and within the appropriate dose especially
diuretics at morning to avoid nocturia.

 HTN can be controlled by antihypertensive agent here but can’t be cured.

 Thiazide make the skin more sensetive so the use of sun block is important.