39
CHAPTER 7
FIGURE 6-2. Electrocardiogram showing torsades de pointes.
FIGURE 6-3. The Heartstart Home Defibrillator, an automated external
defibrillator (AED) device approved by the FDA for home use. (Photo-
graph courtesy of Philips Medical Systems, Bothell, Washington.)
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.
■ SELF-STUDY ASSIGNMENTS
1. Search the Internet for commercially available automated exter-
nal defibrillator (AED) devices (see Fig. 6-3 for one example). Ex-
plain how such a device would be used by a layperson during a
cardiac arrest that occurred in the home or workplace.
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 endotra-
cheal 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 Emer-
gency Cardiovascular Care. Circulation 2005;112(24):Suppl IV.
2. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guide-
lines for management of patients with ventricular arrhythmias and the
prevention of sudden cardiac death: a report of the American College
Hypertension
of Cardiology/American Heart Association Task Force and the Euro-
pean Society of Cardiology Committee for Practice Guidelines (Writ-
ing 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.
7
HYPERTENSION
Salty Sam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level II
Julie M. Koehler, PharmD
James E. Tisdale, PharmD, BCPS, FCCP
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
• Classify blood pressure according to JNC 7 Guidelines, and dis-
cuss the correlation between blood pressure and risk for car-
diovascular morbidity and mortality.
• Identify medications that may cause or worsen hypertension.
• Discuss complications (e.g., target organ damage, clinical cardio-
vascular disease) that may occur as a result of uncontrolled and/
or long-standing hypertension and identify cardiovascular risk
factors.
• Establish goals for the treatment of hypertension, and choose
appropriate lifestyle modifications and antihypertensive regi-
mens based on patient-specific characteristics and co-morbid
disease states.
• Provide appropriate patient counseling for antihypertensive
drug regimens.
PATIENT PRESENTATION
! Chief Complaint
“I just moved to town, and I’m here to see my new doctor for a check-
up. 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!”
 40
! HPI HEENT
Sam Street is a 62-year-old African-American male who presents to TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages,
SECTION 2

his new family medicine physician for evaluation and follow-up of his exudates, or papilledema
medical problems. He generally has no complaints, except for occa-
sional mild headaches and some dizziness after he takes his morning Neck
medications. He states that he is dissatisfied with being placed on a Supple without masses or bruits, no thyroid enlargement or lym-
low sodium diet by his former primary care physician. He reports a phadenopathy
“usual” chronic cough and shortness of breath, particularly when
walking moderate distances (states, “I’m just out of shape”). Lungs
Lung fields CTA bilaterally. Few basilar crackles, mild expiratory
Cardiovascular Disorders

! PMH wheezing
Hypertension × 15 years
Heart
Type 1 diabetes mellitus
Chronic obstructive pulmonary disease, Stage 2 (Moderate) RRR; normal S1 and S2. No S3 or S4
Benign prostatic hyperplasia
Abd
Chronic kidney disease
Soft, NTND; no masses, bruits, or organomegaly. Normal BS.
! FH
Genit/Rect
Father died of acute MI at age 71. Mother died of lung cancer at age
Enlarged prostate; benign
64. Mother had both HTN and DM.
Ext
! SH
No CCE
Former smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports
moderate amount of alcohol intake. He admits he has been nonad- Neuro
herent to his low sodium diet (states, “I eat whatever I want.”) He No gross motor-sensory deficits present. CN II–XII intact. A & O × 3.
does not exercise regularly and is limited somewhat functionally by
his COPD. He is retired and lives alone. ! Labs

! Meds Na 142 mEq/L Ca 9.7 mg/dL Fasting Lipid Spirometry

K 4.8 mEq/L Mg 2.3 mEq/L Panel (6 months ago)
Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM Cl 101 mEq/L HbA1C 6.2% Total Chol 169 FVC 2.38 L
Insulin 70/30, 24 units Q AM, 12 units Q PM CO2 27 mEq/L Alb 3.5 g/dL mg/dL (54% pred)
Doxazosin 2 mg po Q AM BUN 22 mg/dL Hgb 13 g/dL LDL 99 mg/dL FEV1 1.21 L
Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath SCr 1.6 mg/dL Hct 40% HDL 40 mg/dL (38% pred)
Glucose 136 WBC 9.0 × 103/mm3 TG 151 mg/dL FEV1/FVC 51%
Tiotropium DPI 18 mcg 1 capsule INH daily mg/dL Plts 189 × 103/mm3
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 ! UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–)
! All ketones, (–) bilirubin, (–) blood, (–) nitrite, RBC 0/hpf, WBC 1–2/
PCN—Rash hpf, neg bacteria, 1–5 epithelial cells

! ECG
! ROS
Normal sinus rhythm
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 ! ECHO (6 months ago)
years. He complains of occasional headaches, which are usually Mild LVH, estimated EF 45%
relieved by acetaminophen, and he denies blurred vision and chest
pain. He states that his shortness of breath is “usual” for him, and ! Assessment
that his albuterol helps. He denies experiencing any hemoptysis or
epistaxis; he also denies nausea, vomiting, abdominal pain, cramp- 1. Hypertension, uncontrolled
ing, diarrhea, constipation, or blood in stool. He denies urinary 2. Type 1 diabetes mellitus, controlled on current insulin regimen
frequency, but states that he used to have difficulty urinating until 3. Moderate COPD, stable on current regimen
his physician started him on doxazosin a few months ago.
4. BPH, symptoms improved on doxazosin
! Physical Examination

Gen
WDWN, African-American male; moderately overweight; in no QUESTIONS
acute distress
Problem Identification
VS 1.a. Create a list of this patient’s drug-related problems, including
BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), any medications which may be contributing to the patient’s
RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2'' uncontrolled hypertension.

1.b. How would you classify this patient’s HTN (e.g., Prehyperten-
sion, 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
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 co-
morbidities and individual patient considerations should be
taken into account when selecting pharmacologic therapy for
his HTN? How might Mr. Street’s HTN medications poten-
tially affect his other medical problems?
Optimal Plan
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 manage-
ment 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 pharma-
cotherapeutic 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
41
CHAPTER 7
Hypertension
FIGURE 7-1. The LifeSource UA-767 Plus—One-Step Plus Memory digi-
tal 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.
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 Hyperten-
sion (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 Hyperten-
sion 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.