Practical Clinical Pharmacy II – Lab.

5
Drugs Act on Cardiovascular System
Dr. Shahad Mohsin

Case 1
A 55-year-old woman of African Caribbean origin is found to have consistently elevated
blood pressure over several weeks, her lowest reading being 155/98mmHg. She is
overweight and has diabetes, and is being treated with metformin. Her renal function
and urinalysis are both normal.
Questions:
1. Should drug therapy be initiated for her hypertension? Why?
2. What your advices' for non-pharmacological treatment?
3. If her hypertension was treated with drugs, which agents offer particular
advantages, and which should be avoided?
Answers
Case 1 Q 1
 Provided her blood pressure has been measured accurately over several weeks, it
should be treated, since her diabetes is an important additional risk factor.
 Patients whose blood pressure is in the range 140–159/90–99mmHg should be
observed annually unless they have evidence of target organ damage, cardiovascular
complications, diabetes or a cardiovascular risk >20% over 10 years, in which case
drug treatment should be offered.
Case 1 Q 2
 Non-pharmacological interventions should also take place in parallel. Restriction of
salt intake may be particularly helpful in people of African Caribbean race and
weight reduction would benefit her hypertension and diabetes.
 Diet emphasizes fruit, vegetables, and low-fat dairy produce in addition to fish, low-
fat poultry and whole grains while minimizing red meat, dessert and sweetened
drinks.
 Regular aerobic exercise, at least 3 times a week for at least 30 min derives maximum
benefit.

1
Case 1 Q 3
 ACE inhibitors are an attractive choice for diabetic patients who have nephropathy.
However, there is no evidence of nephropathy in this patient and ACE inhibitors are
less effective antihypertensives in people of African Caribbean origin. Why?
 β-Blockers reduce hypoglycaemic awareness; this is not a contraindication in this
case since metformin does not cause hypoglycaemia. However, β-blockers are also
less effective in those of African Caribbean descent.
 Diuretics work well in African Caribbean patients with hypertension, but may
worsen glucose tolerance and may not, therefore, be the most appropriate first
choice.
 Calcium channel blockers do not have adverse metabolic effects and are effective in
people of this origin and would, therefore, be an appropriate choice.
Case 2
A 55-year-old man presents to his primary care doctor complaining of tightness in his
chest when he digs the garden. It relieves when he has a rest. On investigation he has a
raised serum glucose concentration and is considered to be a newly diagnosed non-
insulin-dependent type II diabetic.
Question
What cardiovascular investigations and treatments should this patient receive?
Answer
 The patient's blood pressure and ECG should be checked and he should be examined
for signs of hypertensive or diabetic target organ damage, including albuminuria. His
serum lipid profile should be measured.
 He should receive GTN spray or sublingual tablets for the chest symptoms that are
almost certainly angina. What advice do you give to patient when take GTN? why?
 He should take aspirin daily and a statin if his lipid profile is abnormal. Some
prescribers would give a statin in almost all diabetic, CHD patients and likewise an
ACE inhibitor.
 Certainly, any hypertension should be treated aggressively so that the diastolic
pressure is less than 80 mmHg. A β-blocker may also be useful to control blood
pressure and prevent further episodes of angina.
 In view of his relatively young age, a referral to a cardiologist for possible
angiography would be considered.
 Dietary advice and help to stop smoking, if needed, would be given. Diabetic
treatments should be given.

2
Case 3
A 73-year-old lady has a long-standing history of hypertension and intolerance to
antihypertensive drugs. Bendroflumethiazide was associated with acute attacks of gout,
she developed breathlessness and wheezing while taking atenolol, nifedipine caused
flushing and headache, and doxazosin was associated with intolerable postural
hypotension. Four weeks earlier she had been started on enalapril but was now
complaining of a dry persistent cough.
Questions
1. Is the patient's cough likely to be an adverse effect of enalapril?
2. What other options are available for controlling her blood pressure?
Answers
Case 3 Q 1
 Yes it is. A dry cough is a common adverse effect of ACE inhibitors. It affects
approximately 10–20% of recipients and is more common in women.
Case 3 Q 2
 Angiotensin receptor blockers can be used in patients intolerant of ACE inhibitors
due to cough. They are unlikely to produce this symptom since they do not inhibit
the metabolism of pulmonary bradykinin. Centrally acting agents such as
methyldopa or moxonidine could also be considered. However, these are not well
tolerated and side effects are quite likely in this patient. A non-dihydropyridine
calcium channel blocker such as verapamil is another alternative. Measurement of
plasma uric acid could also be considered followed by prophylactic treatment with
allopurinol before introducing a diuretic. Alternatively, a trial of spironolactone or
the renin antagonist aliskiren could be considered.