Help on Patient Case

[cream]

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Patient, male, 78 y/o, on Meds for High BP. Takes Lisinopril 30mg and Atenolol 100mg. Patient still effected by high BP in the morning upon waking up. Any suggestions for next plan of action?

 

[Caverject]

Recommend a nice greasy hamburger

 

[CaliCPhT]

Recommend a nice greasy hamburger

Yes, serve it with french fries coated in melted butter!!

True story - I used to work food and beverage for a golf course during my undergrad and one of the golfers seriously ordered a Hamburger - RARE with french fries drizzled with melted butter. I put the order in with the kitchen, and the cook was absolutely horrified. He asked if he'd like a heart attack on the side! LOL

 

[WVUPharm2007]

Patient, male, 78 y/o, on Meds for High BP. Takes Lisinopril 30mg and Atenolol 100mg. Patient still effected by high BP in the morning upon waking up. Any suggestions for next plan of action?

How long have they been on this regimen? If it's been a day, wait it out a bit. Also, what are his comorbidities? Renal function?

Or if you don't want to wait for us, just google "JNC 7". It'll tell you the answer to this question and a bunch of other **** you probably don't even care about.

 

[sdn1977]

How long have they been on this regimen? If it's been a day, wait it out a bit. Also, what are his comorbidities? Renal function?

Or if you don't want to wait for us, just google "JNC 7". It'll tell you the answer to this question and a bunch of other **** you probably don't even care about.

Good answer! You do have a future!😀

 

[Aznfarmerboi]

Besides waiting for a few more days, check to see how the bp is taken. Take a few more and average it out. You can also add a diuretic (almost cant go wrong with that answer). Remember that blood pressure is regulated through many ways by the body, and if one way is block, the baroreceptors will compensate through another way.

 

[cream]

He takes meds at 8p.m. and goes to bed an hour later. Also takes 1/2 tab 0.25 mg of Digoxin per day for the past 25 years. Normal BP is about 135/70 during the day. Had Open Heart Surgery 2 years ago. About 3 years ago started experiencing High BP in Morning, 175/90. Stated that in the past after he would eat and it would lower (sometimes too low 100/50). Now BP not affected due to eating. Was taking Lipitor for 3 weeks but stopped due to muscle pain. Normal BMA.

 

[pinkyrx]

What is his CrCl?

 

[Epic]

Yes, serve it with french fries coated in melted butter!!

True story - I used to work food and beverage for a golf course during my undergrad and one of the golfers seriously ordered a Hamburger - RARE with french fries drizzled with melted butter. I put the order in with the kitchen, and the cook was absolutely horrified. He asked if he'd like a heart attack on the side! LOL

ehh...that was me..

 

[ButlerPharm.D.]

Also, I would monitor his potassium closesly considering he is taking digoxin and many of the medications used to control hypertension can effect potassium levels; especially ACE-I.

 

[WVUPharm2007]

This is the point where one says "there still ain't enough info to direct therapy optimally."

Does he have CHF or is he taking the dig for afib? How's his kidneys? What other comorbidities?

The postprandial hypotension suggests the possibility of an autonomic dysfunction. Does the patient have parkinsonism? Diabetes? If it has something to do with too much blood going in transit to the intestines, one may consider Sandostatin....or telling him to drink more caffeine. And if that is the case, his meds still need tweaking around the time he isn't in the fed state as he is still typically hypertensive....thiazides are considered first line therapy should there not be any contraindication to their use...maybe add that. If he has CHF, you'll want to keep him on the ACEI and BB as they are the only drugs shown to improve mortality rates in CHF patients...cuz dig just treats the symptoms, not the underlying RAS and adrenergic compensatory mechanisms that ACEs and BBs take care of...of course if he is taking the dig for afib, it's a different animal.

Is this for school or something?

 

[Epic]

Patient, male, 78 y/o, on Meds for High BP. Takes Lisinopril 30mg and Atenolol 100mg. Patient still effected by high BP in the morning upon waking up. Any suggestions for next plan of action?

Add norvasc...or consider ARB. Change atenolol to Toprol XL.


Ehhh...not enough info.

 

[twester]

Add norvasc...or consider ARB. Change atenolol to Toprol XL.


Ehhh...not enough info.

Seriously.

Does "open heart surgery" mean something like a valve replacement? If he as no other comorbidities, taper him off atenolol and try HCTZ.

 

[Epic]

Seriously.

Does "open heart surgery" mean something like a valve replacement? If he as no other comorbidities, taper him off atenolol and try HCTZ.

well...with HCTZ, pt may get dig toxicity due to hypokalemia..unless K+ is added to the regimen.

 

[twester]

Could we give him spironolactone?

Edit: nevermind - then he'd have to have his dig dose adjusted... And I'm not reading the JNC-7 again until finals.

 

[WVUPharm2007]

Maybe, maybe not. You tell me.

 

[twester]

Maybe, maybe not. You tell me.

 

[golf299]

^^^^

If he has no comorbidities we should ADD HCTZ, not replace the atenolol with it. As long as he's tolerating the atenolol well, we shouldn't replace meds, we should add them.

Dr. Saseen wouldn't be happy with you, George!