Pharmacotherapy Case Study 2: Hypertension By: Dr. Nehad Ahmed

 

Chief Complaint:

The patient presents for a routine follow-up visit with complaints of occasional headaches and dizziness. The patient is concerned about elevated blood pressure readings at home.

Subjective Data:

History of Present Illness (HPI):
The patient reports occasional headaches and dizziness, which have become more frequent over the past few months. The headaches are described as mild and typically occur in the morning. The dizziness is usually short-lived and does not cause fainting or falls. The patient also mentions feeling more fatigued than usual, but there are no complaints of chest pain, shortness of breath, or palpitations. Blood pressure readings at home have ranged from 150/95 mmHg to 160/100 mmHg.

Past Medical History (PMH):

Primary Hypertension (diagnosed 3 years ago)

Obesity (BMI 32 kg/m²)

Hyperlipidemia

Family history of hypertension (both parents) and stroke (father)

Medications:

Lisinopril 10 mg daily

Atorvastatin 20 mg nightly

Allergies:

No known drug allergies.

Family History:

Father with hypertension, myocardial infarction at age 58, and a stroke at age 70.

Mother with hypertension and hyperlipidemia.

Social History:

Non-smoker

Occasional alcohol use (1-2 drinks per week)

Sedentary lifestyle, with no regular exercise

Diet high in processed foods and low in fruits/vegetables

Review of Systems:

Cardiovascular: Denies chest pain or palpitations.

Neurological: Occasional mild headaches, dizziness, no syncope.

Respiratory: No shortness of breath or cough.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Genitourinary: No urinary changes or incontinence.

Objective Data:

Vital Signs:

Blood Pressure: 158/98 mmHg (right arm, seated position)

Heart Rate: 76 bpm

Respiratory Rate: 18 breaths/min

Temperature: 36.7°C

Weight: 92 kg (BMI 32 kg/m²)

Height: 170 cm

Physical Exam:

General: Overweight, in no acute distress.

Cardiovascular: Regular heart rate, no murmurs or gallops.

Respiratory: Clear lungs bilaterally, no wheezes or crackles.

Neurological: Alert and oriented, no focal deficits.

Extremities: No edema, pulses normal bilaterally.

Skin: No rashes or lesions.

Laboratory Results:

Electrolytes: Sodium 139 mEq/L, Potassium 4.1 mEq/L

Creatinine: 1.0 mg/dL (baseline)

Blood Glucose: 104 mg/dL (fasting)

Lipid Profile:

Total Cholesterol: 215 mg/dL

LDL: 130 mg/dL

HDL: 45 mg/dL

Triglycerides: 180 mg/dL

Urinalysis: Negative for protein, glucose, or blood.

ECG: Normal sinus rhythm, no signs of ischemia.

Additional Diagnostic Tests:

Ambulatory Blood Pressure Monitoring (ABPM): Average blood pressure of 152/96 mmHg over 24 hours.

Echocardiogram: Normal left ventricular ejection fraction (LVEF), no signs of left ventricular hypertrophy (LVH).

Assessment:

The patient is presenting with poorly controlled primary hypertension, with blood pressure consistently elevated above target levels despite being on lisinopril. The patient also reports mild symptoms of headaches and dizziness, which may be related to the hypertensive state, though other causes should be considered. There is a significant family history of cardiovascular disease, including hypertension and stroke, increasing the patient's risk for cardiovascular events.

Given the patient's BMI of 32 kg/m² and hyperlipidemia, there is also an increased risk for cardiovascular complications. The patient’s blood pressure readings are above the recommended target of <140/90 mmHg for most adults with hypertension, indicating the need for further pharmacologic therapy adjustment.

Plan:

Lifestyle Modifications:

Dietary changes: Encourage a low-sodium, high-potassium, and DASH (Dietary Approaches to Stop Hypertension) diet. Increase fruit and vegetable intake, reduce processed food.

Exercise: Recommend at least 150 minutes of moderate-intensity aerobic exercise per week (e.g., brisk walking).

Weight loss: Encourage weight reduction through a combination of diet and exercise to reduce the risk of cardiovascular disease and improve blood pressure control.

Limit alcohol consumption to no more than 1-2 drinks per day.

Pharmacotherapy Adjustments:

Increase Lisinopril dose to 20 mg daily to better control blood pressure.

Add Amlodipine (Calcium Channel Blocker) 5 mg daily for better blood pressure control and to help reduce peripheral vascular resistance.

Consider Hydrochlorothiazide (Thiazide Diuretic) 12.5 mg daily if blood pressure remains elevated after 4-6 weeks of the current therapy. This is effective in reducing volume overload and may have additional beneficial effects in combination with the other agents.

Statin therapy (Atorvastatin) will be continued at 20 mg nightly, given the patient’s lipid profile and history of hyperlipidemia.

Monitoring & Follow-up:

Blood pressure monitoring: Encourage the patient to monitor their blood pressure at home twice a week and bring readings to follow-up appointments.

Lab tests: Monitor renal function (creatinine, potassium) every 6 months given the use of lisinopril and amlodipine.

Lipid profile: Repeat in 3 months to assess the effectiveness of atorvastatin therapy.

Education:

Provide education on the importance of adhering to prescribed medications and attending regular follow-up visits.

Discuss potential side effects of medications (e.g., dizziness with amlodipine, electrolyte imbalances with diuretics).

Emphasize the need for lifestyle modifications, including diet and exercise, for long-term blood pressure management.

Referral:

Consider referral to a dietitian to assist with dietary changes and weight loss.

Refer to a hypertension specialist if blood pressure remains difficult to control despite medication adjustments.

Discussion:

Hypertension is a common and chronic condition that often requires a multifaceted approach for management, including both pharmacological and non-pharmacological strategies. This patient’s blood pressure remains elevated despite being on a low-dose ACE inhibitor, indicating the need for therapy optimization. The addition of a calcium channel blocker and potentially a diuretic can help achieve better control of the patient’s blood pressure. Lifestyle changes, such as dietary modifications, weight loss, and increased physical activity, are essential components of hypertension management and can significantly impact long-term outcomes.

Prognosis:
With appropriate pharmacotherapy and lifestyle modifications, the patient’s blood pressure can likely be better controlled, reducing the risk of long-term complications such as stroke, myocardial infarction, and renal disease. However, the patient’s long-term prognosis depends on adherence to the prescribed treatments and lifestyle changes.