HYPERTENSION

Pass the Salt, Please . . . . . . . . . . . Level II

LEARNING OBJECTIVES
After completing this case study, the reader should be able to:

• 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 HTN.
• Discuss complications (eg, target organ damage) that may occur as a result of uncontrolled and/or
long-standing HTN.
• Establish goals for the treatment of HTN, and choose appropriate lifestyle modifications and
antihypertensive regimens based on patient-specific characteristics, comorbid disease states, and
current HTN guidelines.
• Provide appropriate patient counseling for antihypertensive drug regimens.

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!”

HPI
James Frank is a 64-year-old black 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.

PMH
HTN × 14 years
Type 2 diabetes mellitus × 16 years
COPD, GOLD 3/Group C
BPH
CKD
Gout
 FH
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.

SH
Former smoker (quit 6 years ago; 35 pack-year history); 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. He works at Wal-Mart and has healthcare insurance through his employer.

Meds
Triamterene/hydrochlorothiazide 37.5 mg/25 mg PO Q AM
Insulin glargine 36 units SC daily
Insulin lispro 12 units SC TID with meals
Doxazosin 2 mg PO Q AM
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

All
PCN—rash.

ROS
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
Gen
WDWN, black male; moderately overweight; in no acute distress

VS
BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg), HR 76 bpm (regular), RR 16/min, T 37°C; Wt 95
kg, Ht 6′2″

HEENT
TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema

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

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

Neuro
No gross motor-sensory deficits present. CN II–XII intact. A & O × 3

Labs

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.

ECG
Abnormal ECG: normal sinus rhythm; left atrial enlargement; left axis deviation; LVH

ECHO (6 Months Ago)

Assessment

1. HTN, uncontrolled

2. Type 2 DM, controlled on current insulin regimen

3. COPD, stable on current regimen

4. BPH, symptoms improved on doxazosin

5. Gout, controlled on current regimen

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.
1.b. How would you classify this patient’s HTN, according to current HTN guidelines?
1.c. 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 his goal blood pressure).

Therapeutic Alternatives
3.a. What lifestyle modifications should be encouraged for this patient to help 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 Frank’s HTN
medications potentially affect his other medical problems?

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 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. Describe the major causes of secondary HTN and the methods by which those could be ruled out in
this patient.
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 comorbidities or characteristics:
• Severe persistent asthma
• Major depression
• Ischemic heart disease with a history of MI
• Cerebrovascular accident
• Peripheral arterial disease
• Isolated systolic HTN
• Migraine headache disorder
• Liver disease
• Renovascular disease (bilateral or unilateral renal artery stenosis)
• Heart failure with reduced EF
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. 13-1.

FIGURE 13-1. The LifeSource UA-767 Plus—One-Step Plus Memory digital home blood pressure monitor. (Photo courtesy of
A&D Medical, Milpitas, California.)

CLINICAL PEARLS
1. The risk of hemorrhagic stroke may be increased by the use of aspirin therapy in patients with
uncontrolled HTN (eg, BP > 150/90 mm Hg).

2. The majority of hypertensive patients will require two or more blood pressuring-lowering
medications to achieve recommended blood pressure goals.

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. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the 3 management of
hypertension in the community: a statement by the American Society of Hypertension and the
International Society of Hypertension. J Clin Hypertension 2014;16:14–26.
doi:10.1111/jch.12237.
3. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high
blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA 2013. doi:10.1001/jama2013.284427.
4. American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care
2016;39(1 Suppl):S1–S112.
5. KDIGO clinical practice guideline for the management of blood pressure in kidney disease.
Kidney Int Suppl 2012; 2: 337–414. doi:10.1038/kisup.2012.46.
6. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to
reduce cardiovascular risk: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines. Circulation 2013. doi:10.1161/01
.cir.0000437740.48606.d1.
7. 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.
8. Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting
enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med
2000;342:145–153.
9. Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular
and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and the
MICRO-HOPE substudy. Lancet 2000;355:253–259.
10. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major
cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA
2000;283:1967–1975.
11. Hou FF, Zhang X, Xie D, et al. Efficacy and safety of benazepril for advanced chronic renal
insufficiency. N Engl J Med 2006;354:131–140.