Cardio Pt Case

[JamesL1585]

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Hey guys, could really use your help.

Basically I have a 78 y/o vietnamese woman, w/ PMH of CABG 6 months ago, and triple bypass, she has other history of Hypertension (uncontrolled), T1DM, Osteoporosis, and NSTEMI about 6 months ago as well.

Everything is well managed except her BP, which is 162/58 (isolated systolic hypertension), shes currently taking Toprol XL 100mg, and Lisinopril 40... still uncontrolled, what would your 3rd agent of choice be? Lifestyle modifications already suggested.

By the way she is a smoker for 40 yrs at 1/2 a pack per day (which we are working to get her off asap). FH: Mother died of MI @ 70, father had MI but still living

I was looking for about 2 hours and came up with nothing from literature. If you have any lit on this, that would be great as well. I was thinking of adding a Thiazide, but my classmate recommended aldosterone receptor blocker or CCB. What do you think?

Thanks in advance!

 

[owlegrad]

Hey guys, could really use your help.

Basically I have a 78 y/o vietnamese woman, w/ PMH of CABG 6 months ago, and triple bypass, she has other history of Hypertension (uncontrolled), T1DM, Osteoporosis, and NSTEMI about 6 months ago as well.

Everything is well managed except her BP, which is 162/58 (isolated systolic hypertension), shes currently taking Toprol XL 100mg, and Lisinopril 40... still uncontrolled, what would your 3rd agent of choice be? Lifestyle modifications already suggested.

By the way she is a smoker for 40 yrs at 1/2 a pack per day (which we are working to get her off asap).

I was looking for about 2 hours and came up with nothing from literature. If you have any lit on this, that would be great as well. I was thinking of adding a Thiazide, but my classmate recommended aldosterone receptor blocker or CCB. What do you think?

Thanks in advance!

My first thought would be a compliance issue. Good luck with the case!

 

[JamesL1585]

My first thought would be a compliance issue. Good luck with the case!

Thanks, but she is compliant.

 

[ForcedEntry]

What is her HR?

 

[RX CARE]

What is the trending of her heart rate? If it is pretty stable to maintain a reasonable cardiac output, she may benefit from hydralazine or a nitrate like isosorbide. Just my opinion and suggestion. Please research further****

 

[KARM12]

Amlodipine would be my next choice. Check HR and up her BB if possible? With a hx of heart disease, I know many cardiologists that like to push the BB as much as possible.

I'd want more info before initiating a thiazide because of her age. I would expect a degree of renal dysfn.

 

[Old Timer]

Unless there is diminished renal function, I would go thiazides for isolated systolic hypertension.

 

[powertoold]

Excuse my ignorance, but isn't she indicated for an aldosterone antagonist (spironolactone 12.5mg => 25mg) as she is post-MI?

Edit: From a cursory Google search, it seems AAs are mostly for post-MI HF. I'll have to look it up further.

Edit 2: I'm not sure a thiazide would be safe. IF she has normal renal function, her CrCl would be around 35, but I doubt she has normal kidneys, and most institutions shy away from thiazides once CrCl < 30-50 (mine is < 50).

 

[RX CARE]

It's really not a safety issue with thiazides with decreased renal function. It's that they just do not work at all. If you really wanna use a thiazide, you should go with metolazone. It works regardless of renal function and actually more potent than HCTZ, but you will have to monitor 'lytes a little closer.

 

[JamesL1585]

No renal insufficiency, still waiting to get her pulse for the next part of the case

 

[Sparda29]

Is this inpatient, outpatient?

 

[Old Timer]

It's really not a safety issue with thiazides with decreased renal function. It's that they just do not work at all. If you really wanna use a thiazide, you should go with metolazone. It works regardless of renal function and actually more potent than HCTZ, but you will have to monitor 'lytes a little closer.

Way too potent and too hard on the kidneys for long term use.

 

[npage148]

What is the trending of her heart rate? If it is pretty stable to maintain a reasonable cardiac output, she may benefit from hydralazine or a nitrate like isosorbide. Just my opinion and suggestion. Please research further****

why a nitrate? they have no indicated use for hypertension in an outpatient setting and are ineffective at treating HTN

I'd suggest HCTZ. Get her Lisinopril/HCTZ combo so she's not taking any extra tabs daily.

I would expect with her hx, there may be some developing CHF and if that's the case her treatment would different

 

[All4MyDaughter]

It's really not a safety issue with thiazides with decreased renal function. It's that they just do not work at all. If you really wanna use a thiazide, you should go with metolazone. It works regardless of renal function and actually more potent than HCTZ, but you will have to monitor 'lytes a little closer.

Thiazides don't work? I thought they were first line agents for HTN. ALLHAT?

 

[bacillus1]

Thiazides don't work? I thought they were first line agents for HTN. ALLHAT?

That was exactly my thought. However, I believe thiazides aren't first-line post-MI. You can still add them though probably. A dihydropyridine CCB would be good too.

 

[Old Timer]

That was exactly my thought. However, I believe thiazides aren't first-line post-MI. You can still add them though probably. A dihydropyridine CCB would be good too.

We are not at first line here. They are already on beta blockers and an ACEI. I really think isolated systolic hypertension responds best to thiazides. I have no data to back up my claim. It's just something that is rattling around in this old cranium.

 

[BMBiology]

Hey guys, could really use your help.

Basically I have a 78 y/o vietnamese woman, w/ PMH of CABG 6 months ago, and triple bypass, she has other history of Hypertension (uncontrolled), T1DM, Osteoporosis, and NSTEMI about 6 months ago as well.

Everything is well managed except her BP, which is 162/58 (isolated systolic hypertension), shes currently taking Toprol XL 100mg, and Lisinopril 40... still uncontrolled, what would your 3rd agent of choice be? Lifestyle modifications already suggested.

By the way she is a smoker for 40 yrs at 1/2 a pack per day (which we are working to get her off asap). FH: Mother died of MI @ 70, father had MI but still living

I was looking for about 2 hours and came up with nothing from literature. If you have any lit on this, that would be great as well. I was thinking of adding a Thiazide, but my classmate recommended aldosterone receptor blocker or CCB. What do you think?

Thanks in advance!

Since the patient has DM, the goal BP should be <130/80. I would start her on hydrochlorothiazide 25mg qd since thiazide is the initial drug of choice and increase to 50mg qd if needed. Lisinopril 40mg/day is already the max. Can't combine HCTZ with lisinopril since there is no 40mg of lisinopril in Zestroretic or Prinizde. If necessary, the next step would be to increase the toprol XL dose and if needed, I would then add amlopidine. Spironolactone is also an option. These drugs would also help her DM and reduce MI risk.

For her MI: add aspirin, nitrate; need to stop smoking and her DM/HTN/lipid need to be managed.

 

[BMBiology]

I'd want more info before initiating a thiazide because of her age. I would expect a degree of renal dysfn.

Just to clarify, when the CrCl <30, thiazides, except metolazone, become ineffective. That is why it is not recommended. However, you can still use a thiazide, just use metolazone.

 

[BMBiology]

Way too potent and too hard on the kidneys for long term use.

If the drug is potent then use a lower dose. Thiazides don't cause nephrotoxicity.

 

[KARM12]

Just to clarify, when the CrCl <30, thiazides, except metolazone, become ineffective. That is why it is not recommended. However, you can still use a thiazide, just use metolazone.

Obviously...that is why I said you would expect an 78 yo to already have some reduced renal fn. I never said it would be toxic on her kidney's. In pts with CrCl <30 you use a loop when a diuretic is needed. We ususally don't use metolazone as a standing diuretic. In general in the hospital we use it to prime the kidney before giving a loop for extra diuresis. I would not use metolazone for reducing BP.

 

[GreyFox2002]

If her HR can tolerate it, definitely max out the Toprol XL to 200 mg. Great benefits post-MI.

Thiazide diuretic would be next best choice. HCTZ at 25 mg; 50 mg has no greater efficacy but increased risk of electrolyte abnormalities.

If both are contraindicated then its time to think about a DHP CCB, probably just amlodipin is fine.

Hydralazine/Isordil (Or Imdur) is usually reversed for patients with LVSD, and in particular, African Americans.

Spironolactone should be reserved for patients with left ventricular systolic dysfunction.

Alpha blockers/clonidine/hydralazine I would avoid.

 

[Praziquantel86]

Thiazides don't work? I thought they were first line agents for HTN. ALLHAT?

Therein lies the rub. If you look at ALLHAT, all-cause mortality was similar among all three treatment groups (chlorthalidone, amlodipine, lisinopril). Rates of CHF, admission for HF and death from HF were all higher in the amlodipine group, but death from cardiac events were similar in all groups. Non-cardiac mortality, on the other hand, was significantly lower in the amlodipine group, and glomerular filtration rate was significantly higher.

I think the reason JNC picked thiazides (really, HCTZ) first line is two-fold. First, and probably most important, the relative increase in CHF and death from CHF scared them away. Second, and this can't be discounted, is that HCTZ was available generically at the time, unlike all the DHPCCBs. So, for a government funded study that would end up primarily affecting government-insured patients, it seemed reasonable.

So to me, its really six to one, half a dozen to the other. Now that CCBs are available generically, I think the large reason for using thiazides first-line is gone. I also think that the renal benefits can't be ignored, and there's a lot of literature in the renal transplant field to back that up. You're really picking between a relative increase in CHF mortality or a relative increase in non-cardiac mortality.

So long story short: pick on your risk factors (not just the convenient, predefined ones). This lady, I would probably go with a thiazide (why not chlorthalidone), based on her cardiac history. Although, if HR can tolerate it, increasing the beta blocker wouldn't be a bad idea either.

Anyways, great case to chat about. It's nice to get back to the basics sometimes.

 

[BMBiology]

Obviously...that is why I said you would expect an 78 yo to already have some reduced renal fn. I never said it would be toxic on her kidney's. In pts with CrCl <30 you use a loop when a diuretic is needed. We ususally don't use metolazone as a standing diuretic. In general in the hospital we use it to prime the kidney before giving a loop for extra diuresis. I would not use metolazone for reducing BP.

Why so serious? Honestly, reading from your previous comment, it does not appear you know much about metolazone. That's unfortunate.

 

[Old Timer]

A couple of things guys:

For those of you pushing the 200mg Toprol as an option, I must respectfully disagree. Remember this a 78 y/o Asian woman. Geriatrics tend to need lower doses to begin with and since the patient is Asian, you can pretty safely assume she is most likely a small woman. So, I personally think that 200mg of Toprol is really a whooper of a dose for this patient.

On the metolazone discussion, is used almost exclusively as Karm suggested to prime the pump before a loop diuretic. It's been a long time since I have seen an order for metolazone dosed on a daily basis. When I was commenting earlier about strength I was speaking about metolazone and not thiazides in general.

As for amlodipine, I think with history of diabetes and MI as well as hypertension, the next thing I would look for in this patient is CHF. Since amlodipine causes pedal edema, you can bet this patient will then have to experience an entire battery of tests to R/O CHF.

Finally, I would start the patient patient on HCTZ 12.5 mg daily and up it to 25 mg if needed. Since thiazides have a flat dose response curve I would not use 50 mg of HCTZ in this patient.

Just one man's recap of the discussion so far.

 

[RX CARE]

😛 There are too many smart people in here. People are thinking too big. In practice, when your patient starts getting really refractory to mainstream guideline therapy, whatever it is that you do, based on your best clinical judgment applies. You may try and see what happens...that's the point of our trade. But it's all on you. Everybody in here probably has a point 😉

 

[KARM12]

Why so serious? Honestly, reading from your previous comment, it does not appear you know much about metolazone. That's unfortunate.

It is unfortunante that you don't have enough practice experience to know when to use metolazone.

 

[BMBiology]

It is unfortunante that you don't have enough practice experience to know when to use metolazone.

Seriously? This is coming from someone who did two years of residency?

 

[Old Timer]

It is unfortunante that you don't have enough practice experience to know when to use metolazone.

Seriously? This is coming from someone who did two years of residency?

Hey guys, knock it off. What you have is a difference of opinion. I tend to side with Karm here. While I can't say it is never used for hypertension. Now in my 28th year of practice, I can say it is rarely used for hypertension.

 

[iphetamine]

She's diabetic and hypertensive, so BB and thiazides should be last to think about. The ESH and ESC suggest ACEI as first line and then CCB as second. BB and thiazides are diabetogenic agents, not recommended for this type of patient.
ALLHAT? 43% of the patients developed new onset diabetes due to the diuretic.

She's diabetic, so we need to put her kidneys into consideration and provide protection, therefore we use a Non-DHP CCB, like verapamil. But I need to know what's her HR and no AV block, first.

 

[kvl1027]

Thiazides don't work? I thought they were first line agents for HTN. ALLHAT?

The statement wasn't that Thiazides don't work at all, just that they don't work when CrCl<30. They work great and are typically considered 1st line in the absence of compelling indications for other agents.

 

[kvl1027]

😛 There are too many smart people in here. People are thinking too big. In practice, when your patient starts getting really refractory to mainstream guideline therapy, whatever it is that you do, based on your best clinical judgment applies. You may try and see what happens...that's the point of our trade. But it's all on you. Everybody in here probably has a point 😉

Very well said, it is rare to find a student who understands this concept. Not that the students are purposely being ignorant, just that they only know what they read. Patients are dynamic and never fit into any particular mold.

I think you hit the nail on the head. At this point, any additional anti-hypertensive (in the absence of contraindications) may work. It's a W.A.G. really. While some options may be better than others, any suggestions can be clinically justified and you just have to try one and see what happens. (in the real world; in your case study, however, your preceptor will likely have a more correct answer and if you don't choose it you will likely fail out of pharmacy college and the pharmacy community will stand over and point down at you while all together giving you the dumb laugh)

 

[Old Timer]

She's diabetic and hypertensive, so BB and thiazides should be last to think about. The ESH and ESC suggest ACEI as first line and then CCB as second. BB and thiazides are diabetogenic agents, not recommended for this type of patient.
ALLHAT? 43% of the patients developed new onset diabetes due to the diuretic.

She's diabetic, so we need to put her kidneys into consideration and provide protection, therefore we use a Non-DHP CCB, like verapamil. But I need to know what's her HR and no AV block, first.

Well again, I must disagree. Thiazdes in low doses do not affect glycemic control and I think they would have a limited effect on patients already diagnosed with Type-I DM. Even if the thiazides would have an adverse impact on blood sugar levels, this could be controlled by adjusting the dose of insulin appropriately.

Try some more to convince me why you think a CCB would better. I don't mean that sarcastically.

 

[JamesL1585]

Glad to see you guys are keeping this interest, I have found a lot of good ideas, Thiazide diuretics keep coming up, and so do CCB's. So we decided to add a Thiazide for now HCTZ 25mg, and wait it out just a little bit then probably add Amlodipine. 🙂

Thanks a lot for all the advice.

 

[Priapism321]

We are not at first line here. They are already on beta blockers and an ACEI. I really think isolated systolic hypertension responds best to thiazides. I have no data to back up my claim. It's just something that is rattling around in this old cranium.

I think the AHA guidelines on resistant hypertension would agree with your cranium.....I would go with chlorthalidone.

http://hyper.ahajournals.org/cgi/reprint/HYPERTENSIONAHA.108.189141

 

[Farmtastic]

What about an ARB? Replace the ACEi with ARB?

Or, how about a non thiazide diuretic, i.e. loop diuretic like Lasix (furosemide)? Would that be acceptable in a diabetic pt since they are preferred for kidney protection?

 

[kvl1027]

What about an ARB? Replace the ACEi with ARB?

Or, how about a non thiazide diuretic, i.e. loop diuretic like Lasix (furosemide)? Would that be acceptable in a diabetic pt since they are preferred for kidney protection?

My question for you is what would be the benefit of an ARB to the ACEi? There is a lot of data showing the benefit of ACEi in post MI and diabetic patients so It doesn't make sense to get rid of it.

With that being said, it is always interesting to hear the reasoning behind a therapeutic decision and we may all learn something.

 

[Old Timer]

What about an ARB? Replace the ACEi with ARB?

Or, how about a non thiazide diuretic, i.e. loop diuretic like Lasix (furosemide)? Would that be acceptable in a diabetic pt since they are preferred for kidney protection?

What about
Minoxidil?
Hydralazine
Methyldopa
Reserpine
Alpha Blockers
Clonidine

Tell me why. Convince me.Priapism321 came with something to backup what he said. When a physician asks you for a recommendation, you can't say um, eh, what about an arb?

I'm trying to get you guys in school to:

A) Think about THIS patient.
B) Apply your general knowledge to this specific case
C) Present your plan
D) Back it up

 

[Farmtastic]

My question for you is what would be the benefit of an ARB to the ACEi? There is a lot of data showing the benefit of ACEi in post MI and diabetic patients so It doesn't make sense to get rid of it.

With that being said, it is always interesting to hear the reasoning behind a therapeutic decision and we may all learn something.

Every patient fits their own mold, and if systolic BP is uncontrolled by ACEi, then maybe the pt. will respond better to an ARB. There is also a small percentage of pts. that respond well to being on both ARB & ACEi. The furosemide is a diurectic which is an alternative to the thiazide suggestion, but it does a better job in protecting kidney function. But you bring up a good point- I think ACEi have lower recurrence & incidence of MI than the ARBs.

 

[Farmercyst]

Why an ARB over an ACEI? Same renal protection, same decrease in BP as far as I'm aware. Only thing I can think of is probably more expensive, even with the newly available losartan. I would avoid spironolactone while on an ACEI to reduce the likelihood of hyperkalemia. What do you think about switching from Toprol to Lopressor? Higher peaks, faster onset. Dosed twice daily might be better than Toprol once daily. You'd have to monitor for hypotension, but it doesn't sound like it'd be an issue. If she tolerates the change you could go with Lopresor HCT.

 

[Old Timer]

Every patient fits their own mold, and if systolic BP is uncontrolled by ACEi, then maybe the pt. will respond better to an ARB.

What makes you say that? If a physician wants an answer, they don't want a maybe.

There is also a small percentage of pts. that respond well to being on both ARB & ACEi.

Which patients? Does this patient fit a certain demographic that warrants this recommendation?

The furosemide is a diurectic which is an alternative to the thiazide suggestion, but it does a better job in protecting kidney function. But you bring up a good point- I think ACEi have lower recurrence & incidence of MI than the ARBs.

Do we need to concern ourselves with this for this patient? If that's the case, why use thiazides at all seeing as loop diuretics exert a reno-protective effect?

I go back to:

• Think about THIS patient.
• Apply your general knowledge to this specific case
• Present your plan
• Back it up

 

[kvl1027]

Why an ARB over an ACEI? Same renal protection, same decrease in BP as far as I'm aware. Only thing I can think of is probably more expensive, even with the newly available losartan. I would avoid spironolactone while on an ACEI to reduce the likelihood of hyperkalemia. What do you think about switching from Toprol to Lopressor? Higher peaks, faster onset. Dosed twice daily might be better than Toprol once daily. You'd have to monitor for hypotension, but it doesn't sound like it'd be an issue. If she tolerates the change you could go with Lopresor HCT.

Does an ARB provide the same degree of renal protection as an ACEi? What about the fact that "THIS" patient is post MI? Do ARB's prevent cardiac remodeling? Think about where an ACEi works in the "cascade" to decrease blood pressure, then think about where the ARB works in the "cascade", do you think it will provide a significant reduction in BP, by adding an ARB? How many commercially available combo products contain both an ACEi and an ARB and why?

OLD TIMER is more well spoken than I, but I think we are trying to get the same thing here.

There are multiple correct answers to this case, so long as you can back them up. If you say "I think this does" to a Doc, they may never ask you again if you can't provide a sound recommendation with some data or a reason behind you recommendation. Sometimes the basis can even be as simple as "we had a similar pt last month, who was also elderly and asian and adding an ARB achieved the results we were looking for", not a lot of physicians would go for this kind of recommendation, but it is better than "I think".

 

[Farmercyst]

Does an ARB provide the same degree of renal protection as an ACEi? What about the fact that "THIS" patient is post MI? Do ARB's prevent cardiac remodeling? Think about where an ACEi works in the "cascade" to decrease blood pressure, then think about where the ARB works in the "cascade", do you think it will provide a significant reduction in BP, by adding an ARB? How many commercially available combo products contain both an ACEi and an ARB and why?

OLD TIMER is more well spoken than I, but I think we are trying to get the same thing here.

There are multiple correct answers to this case, so long as you can back them up. If you say "I think this does" to a Doc, they may never ask you again if you can't provide a sound recommendation with some data or a reason behind you recommendation. Sometimes the basis can even be as simple as "we had a similar pt last month, who was also elderly and asian and adding an ARB achieved the results we were looking for", not a lot of physicians would go for this kind of recommendation, but it is better than "I think".

ACEs and ARBs in combination are found to damage the kidney's medium/long term. That's why no combo products. The data is in the ACEIs for heart remodeling not in ARBs, last I read. As for post MI, BBs and ACEIs, and Ald Ants are where it's at based on JNC7's list of compelling indications. I wouldn't do ACEI and Aldosterone Antagonists together without monitoring Potassium for awhile. After that thiazides are listed for HF, DM, and stroke prevention. That would be my next choice. After a cursory glance it does appear XL is better than IR from a mortality viewpoint.

 

[Old Timer]

What I am trying to get at is, there is a right answer for this patient. With the constellation of problems and current medications, I really think that either 12.5mg of HCTZ or 25mg of Chlorthalidone is the appropriate treatment.

For those of you who think an ARB or a CCB would be better, show me where I am wrong. I'm just an old man stuck on the bench for 28 years. No Medline, no resources. Pretend I am the doctor you need to convince that you have the answer for this patient.

Patients do not always fit into the neat patterns in the guidelines we go by. That's why they are guidelines and not commandments. That's why generalities are dangerous.

 

[kvl1027]

ACEs and ARBs in combination are found to damage the kidney's medium/long term. That's why no combo products. The data is in the ACEIs for heart remodeling not in ARBs, last I read. As for post MI, BBs and ACEIs, and Ald Ants are where it's at based on JNC7's list of compelling indications. I wouldn't do ACEI and Aldosterone Antagonists together without monitoring Potassium for awhile. After that thiazides are listed for HF, DM, and stroke prevention. That would be my next choice. After a cursory glance it does appear XL is better than IR from a mortality viewpoint.

There we go, that's better!!!