Jemima R.

Jacot

BSN-4, A

June 20,2012

CASE STUDY Scenario 1: A Patient with Hypertension & Type II Diabetes Mellitus
A 55 y/o Male was diagnosed in Spring 2010 with Type II Diabetes Mellitus-treated with Metformin - A1c of 7.5; HTN on Clonidine, Metoprolol, Lisinopril. BP is consistent, 130- 140 / 80s. Dysplipidemia and previously diagnosed Coronary Disease on Atorvastatin 40 mg daily; Overweight works overseas for 8-10 weeks at a time, then returns home for 3 weeks. Most of his medications chosen on the basis of cost he was self-insured at the time. Initial Findings: LDL-C HDL-C TG TC Goal < 100 mg/dL > 40 mg/dL < 150 mg/dL < 200 mg/dL Result 67 mg/dL 37 mg/dL 138 mg/dL 130 mg/dL

Non-HDL-C is < 100. You would assume he is at goal.

Treatment: Intensified Metformin therapy, advised weight loss, increased exercise. 3 months later, A1c < 7.0%. Reviewed DASH diet, advised sodium reduction, weight loss for BP. Also advised to monitor BP closely. Late in 2011, the patient was able to obtain insurance through employer. During a follow up visit, adjustments were made for HTN added Amlodipine to regimen, BP improved to 130/80 mmHg range consistently. Follow up Labs: LDL-P LDL-C HDL-C TG TC Goal < 1000 nmol/L < 100 mg/dL > 40 mg/dL < 150 mg/dL < 200 mg/dL Result 1539 nmol/L - indicates residual risk 88 mg/dL 38 mg/dL 159 mg/dL 138 mg/dL

Dysplipidemia Atorvastatin continued at 40 mg daily. Ezetimibe 10 mg added to regimen. 3 months later (early 2012), Hypertension stable with Metoprolol, Lisinopril, Clonidine, Amlodipine BP readings consistently 120s / 70s mmHg; DM2 stable with Metformin, increased activity, weight loss, A1c of 6.9.%. Dyslipidemia on Lipitor 40 mg, Ezetimibe 10 mg daily.

NMR LipoProfile test reveals: Goal LDL-P < 1000 nmol/L LDL-C < 100 mg/dL HDL-C > 40 mg/dL Non-HDL-C <130 mg/dL TG < 150 mg/dL TC < 200 mg/dL

Result 1201 nmol/L 61 mg/dL 38 mg/dL 82 mg/dL 103 mg/dL 120 mg/dL

BP at goal, diabetes stable with acceptable A1c. Dyslipidemia could still be optimized in this patient. If we had not reviewed the NMR LipoProfile test at the 2011 visit, residual CVD risk would have been unknown (by all standard measures of CV risk, he was at goal -LDL-C 88 mg/dL and Non-HDL-C 100 mg/dL), despite quite significantly elevated LDL-P of 1539 nmol/L. Most current labs indicate improvement in this area (LDL- C 61 mg/dL, Non-HDL-C 82 mg/dL, LDL-P 1201 nmol/L), although really pushing him to an LDL-P goal of < 1000 nmol/L would be an option. Ways to accomplish this would include substituting a more potent statin (rosuvastatin) for the atorvastatin or adding another agent such as colesevelam (a bile acid sequestrant). The bile acid sequestrant would improve both his LDL-P and lower A1c further.

HYPERTENSIVE CRISIS:
a) Hypertensive Emergency Higher levels of stage 2 hypertension with acute MI, unstable angina, acute pulmonary edema, heart failure, intracerebral hemorrhage, aortic dissection, ecclampsia, encephalopathy b) What is Hypertensive Urgency Higher levels of Stage 2 hypertension with headache, shortness of breath, anxiety, epistaxis; no Target Organ Damage (TOD)

Scenario 2:
74 year old male comes to a clinic appointment complaining of moderate headache the past week and has no past medical history. He has been taking ibuprofen 200 mg 2-3 x/day and has 5/10 scale headache now. His mother had hypertension. Physical exam: BP 224/120 mm Hg, pulse 72. Normal fundi. No bruits and dorsal pedis pulses are present. S4 gallop. Lungs are clear. Trace ankle edema. Neurological exam normal Lab: BUN 17, Cr 0.7, K 3.8, u/a normal, EKG normal Follow-up BP after 30 minutes: 218/120 mm Hg Treatment: Given 0.2 mg clonidine. After one hour, patient becomes severely dizzy almost to the point of blacking out with SBP in the 60s. Via gurney to Emergency Department where SBP to 90s with a liter of NSS IV. Still dizzy and hospitalized overnight. Next day BP was 146/98 mm Hg. Discharged on HCTZ 25 mg daily.

Scenario 3: 72 year old female is referred to Hypertension Clinic because of labile BP. At home she takes her blood pressure 6x daily and has been instructed to take clonidine 0.1 mg prn SBP > 160 mm Hg, averaging clonidine 2-3 x daily, sometimes within one hour. On lisinopril/hydrochlorothiazide 20/25 mg and atenolol 50 mg daily, her clinic BP is 148/72 mm Hg. She has fatigue, dry mouth, and some dizziness. Her self blood pressure technique is poor. The arm is unsupported and the cuff is too small. The patient is instructed on proper self BP technique and advised to reduce home BPs to no more than once daily, not to use prn clonidine because the prn clonidine puts her at a higher stroke risk. Felodipine 5 mg daily is added to her daily regimen with a follow-up clinic BP of 136/70 mm Hg.

Case Studies 2 & 3: Summary Patient # 2: initiation of a Thiazide diuretic or a Thiazide combination tablet Patient # 3: advance in med regimen; improved self BP training; avoid PRN home BP meds

 Hypertensive Urgency: initiation or advance in meds & scheduled follow-up

Scenario 4: 84 year old female on HCTZ 25 mg comes to clinic with BP 200/92 mm Hg, pulse 76. She is intolerant to Lisinopril with cough, intolerant to Losartan with dizziness, and intolerant to nifedipine with confusion (felt like a zombie) Metoprolol 50 mg BID is added to HCTZ with home BPs of 160s/80s. However she feels overly fatigued and is instructed to decrease Metoprolol to 25 mg BID. Followup BP is 180/82, but she feels better. 6 weeks later, Metoprolol is advanced to 50 mg BID and the patient feels well with follow-up BP 158/76.

Scenario 5: A 56 year old male is referred to the HTN Clinic by his cardiologist. The patient is post MI 3 years ago and has been chest pain free on Clopidogrel 75 mg daily post stenting a year ago. Despite a regime of Atenolol 100 mg and Lisinopril 80 mg, BPs are consistently 150s/80s. Cardiac echo is normal and LDL is 68 on Vytorin 10/40 mg. He is fatigued. HCTZ 25 mg is added to his regime with follow-up BPs 120s/70s. Patient is amazed at the favorable BP response by clinic and self BP determinations, but still feels fatigued. On an antihypertensive/cardiac regimen of atenolol 50 mg and lisinopril/HCTZ 20/25 mg he feels well and maintains BPs 120s/70s.
SBP Reduction: Monotherapy ACEI Advance vs Combination therapy with HCTZ

Scenario 6:
A 72 year old male comes to clinic complaining of bothersome urinary hesitancy, some urinary urgency and bothersome nocturia x 4. He is on no meds and has a BP of 144/72 mm Hg. Chart review shows that over the past 8 months other clinic visit systolic BPs have been 148, 142, 152, and 154 mm Hg. Physical exam, lab, and EKG are normal. Synopsis; treatment for elderly male patient with prostatic obstructive symptomatology and stage 1 hypertension Combination drug therapy: terazosin 1 mg HS and hydrochlorothiazide 12.5 mg AM, warned regarding first dose postural hypotensive effect of terazosin Follow-up BP 132/72 mm Hg standing. Terazosin advanced to 2 mg HS with satisfactory symptomatic improvement Comparison of Doxazosin with Chlorthalidone Conclusions: Doxazosin is NOT recommended as first-line therapy in hypertension. ALLHAT does not allow an assessment of the effect of Doxazosin compared with placebo on the incidence of CVD. The use of Doxazosin as a step-up drug for treating hypertension was not tested in this trial. These findings are likely to apply to all alpha-blockers.

(http://www.lipoprotein.org/case-studies/hypertension-case-studies#video-container)