Patient Case

[cream]

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?

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[PeeWee137]

cortisol peaks in the morning, maybe that has something to do with his elevated bp?

 

[NJWxMan]

Many studies exist today that point towards HT and R sided Heart failure in patients with documented obstructive sleep apnea. I think you should order a sleep study on this patient. This can be done as an in or outpatient basis.

 

[Sureshot83]

Many studies exist today that point towards HT and R sided Heart failure in patients with documented obstructive sleep apnea. I think you should order a sleep study on this patient. This can be done as an in or outpatient basis.

I was also thinking of OSA when I read the original post, so I second this suggestion.

 

[mules05]

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 high is the BP in the morning? What time of day is he taking his meds? Any other meds? Is he med compliant? What's his diet like? Any other physical exam findings? More info might help with figuring out a next step.

 

[RockShox]

Many studies exist today that point towards HT and R sided Heart failure in patients with documented obstructive sleep apnea. I think you should order a sleep study on this patient. This can be done as an in or outpatient basis.

This is interesting; without more specific info I would still think it is a zebra. More likely the patient simply has morning hypertension. It is well known that BP follows a circadian rhythm and it is highest between 6am-noon. This is one reason why MI's and strokes are more common after waking. Anyway, the solution is to continue BP control by drugs and lifestyle. One ACE and a beta-blocker is not enough. I would certainly get more history before the sleep study because no insurance company will pay for a study with only ICD codes for HTN.

I see no info that this patient in in heart failure esp. since the prominent symptom of heart failure is not HTN but dyspnea which is why the NYHA classification of heart failure uses dyspnea for grading. The most sensitive markers are dyspnea, increased BNP, and EKG findings.

The largest study on OSA and HTN do show an odds ratio of 1.47 showing OSA as a possible cause of HTN but that HTN is not concurrent with the Right HF. The Right HF comes from pulmonary HTN or cor pulmonale due to the lungs response to hypoxia.

Keep in mind that this is my opinion based on my understanding so, hell, I could be way wrong, but nevertheless these are my thoughts.

 

[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.

 

[mfreema1]

work him up for non-idiopathic causes of htn, and treat the cause.