Clinical Case Studies

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Clinical Case Studies

• Joel Handler MD
• Director,
• Orange County Kaiser Permanente Hypertension
  Clinic
• Co-leader,
• Southern California Kaiser Permanente
  Hypertension Committee

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Case 1

• 74 year old male comes to a clinic appointment
  complaining of moderate headache the past week
  and has no past medical history. He has been
  taking ibuprofen 200 mg 2-3 x/day and has 5/10
  scale headache now. His mother had hypertension.

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Case 1
Physical exam BP 224/120 mm Hg, pulse 72. Normal
fundi. No bruits and dorsal pedis pulses are
present. S4 gallop. Lungs are clear. Trace ankle
edema. Neurological exam normal Lab BUN 17, Cr
0.7, K 3.8, u/a normal, EKG normal Follow-up BP
after 30 minutes 218/120 mm Hg
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Case 1

• Treatment Given 0.2 mg clonidine. After one
  hour, patient becomes severely dizzy almost to
  the point of blacking out with SBP in the 60s.
• Via gurney to Emergency Department where SBP to
  90s with a liter of NSS IV. Still dizzy and
  hospitalized overnight. Next day BP was 146/98 mm
  Hg. Discharged on HCTZ 25 mg daily.

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Case 2

• 72 year old female is referred to Hypertension
  Clinic because of labile BP. At home she takes
  her blood pressure 6x daily and has been
  instructed to take clonidine 0.1 mg prn SBP gt 160
  mm Hg, averaging clonidine 2-3 x daily, sometimes
  within one hour.
• On lisinopril/hydrochlorothiazide 20/25 mg and
  atenolol 50 mg daily, her clinic BP is 148/72 mm
  Hg.
• She has fatigue, dry mouth, and some dizziness.

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Case 2

• Her self blood pressure technique is poor. The
  arm is unsupported and the cuff is too small.
• The patient is instructed on proper self BP
  technique and advised to reduce home BPs to no
  more than once daily, not to use prn clonidine
  because the prn clonidine puts her at a higher
  stroke risk.
• Felodipine 5 mg daily is added to her daily
  regimen with a follow-up clinic BP of 136/70 mm
  Hg.

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Hypertensive Crisis What is Hypertensive
Emergency? Higher levels of stage 2 hypertension
with acute MI, unstable angina, acute pulmonary
edema, heart failure, intracerebral hemorrhage,
aortic dissection, ecclampsia, encephalopathy Wha
t is Hypertensive Urgency? Higher levels of
Stage 2 hypertension with headache, shortness of
breath, anxiety, epistaxis no Target Organ
Damage (TOD)
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Am I going to stroke out?
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Treatment assumptions for Urgency

• Prompt BP reduction will prevent a hypertensive
  emergency
• Prompt BP reduction is safe
• Prompt BP reduction effects more rapid short term
  BP control

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Mean Arterial BPs in Three Treatment Groups, mm
Hg
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Hypertensive Urgency Drugs

• Drugs tested nifedipine, clonidine, captopril,
  labetalol, prazosin, urapidil, nitroprusside,
  furosemide, nicardipine, lacidipine, fenoldapam
• Adverse effects
• Nifedipine MI, stroke, transient blindness
• Clonidine fatal stroke
• All drugs hypotension

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HTN algorithm Triage

• BPgt180/110
• h/a, anxiety, asx exam no TOD Observe 1hr
  initiate, resume, increase med follow-up within
  3 days
• BPgt180/110
• severe headache,shortness of breath exam stable
  TOD Observe 3 hours, short acting oral agent,
  adjust therapy next day follow-up
• Emergency symptoms, usually with BP gt220/140 to
  ICU

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Hypertension Urgency Caution

• Elevated BP by itself rarely requires emergency
  therapy
• No data exist to show benefit from observed
  sequential treatment for rapid BP reduction.
• Data do suggest that an aggressive approach may
  be harmful
• Urgency a follow-up appointment within a few
  days, following med advance or initiation

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Case Studies 1 2 Summary

• Patient 1 initiation of a thiazide diuretic or
  a thiazide combination tablet
• Patient 2 advance in med regimen improved self
  BP training avoid prn home BP meds
• Hypertensive Urgency initiation or advance in
  meds scheduled follow-up

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Case 3

• 84 year old female on HCTZ 25 mg comes to clinic
  with BP 200/92 mm Hg, pulse 76. She is intolerant
  to lisinopril with cough, intolerant to losartan
  with dizziness, and intolerant to nifedipine with
  confusion (felt like a zombie)

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What is a Zombie ?

• Snake God of Voodoo cults in West Africa
• A corpse revived by a supernatural power or spell
  (Voodoo)
• One who looks or behaves like an automaton
• A tall mixed drink made of various rums, liqueur,
  and fruit juice

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Case 3

• Metoprolol 50 mg BID is added to HCTZ with home
  BPs of 160s/80s
• However she feels overly fatigued and is
  instructed to decrease metoprolol to 25 mg BID.
• Follow-up BP is 180/82, but she feels better.
• 6 weeks later, metoprolol is advanced to 50 mg
  BID and the patient feels well with follow-up
  BP 158/76.

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Case 4

• A 56 year old male is referred to the HTN Clinic
  by his cardiologist. The patient is post MI 3
  years ago and has been chest pain free on
  clopidogrel 75 mg daily post stenting a year ago.
  Despite a regime of atenolol 100 mg and
  lisinopril 80 mg, BPs are consistently 150s/80s.
  Cardiac echo is normal and LDL is 68 on Vytorin
  10/40 mg. He is fatigued.

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Case 4

• HCTZ 25 mg is added to his regime with follow-up
  BPs 120s/70s. Patient is amazed at the
  favorable BP response by clinic and self BP
  determinations, but still feels fatigued.
• On an antihypertensive/cardiac regimen of
  atenolol 50 mg and lisinopril/HCTZ 20/25 mg he
  feels well and maintains BPs 120s/70s.

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SBP Reduction Monotherapy ACEI Advance Vs
Combination therapy with HCTZ
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Case 5

• A 72 year old male comes to clinic complaining
  of bothersome urinary hesitancy, some urinary
  urgency and bothersome nocturia x 4. He is on no
  meds and has a BP of 144/72 mm Hg. Chart review
  shows that over the past 8 months other clinic
  visit systolic BPs have been 148, 142, 152, and
  154 mm Hg. Physical exam, lab, and EKG are normal.

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Case 5

• Synopsis treatment for elderly male patient with
  prostatic obstructive symptomatology and stage 1
  hypertension
• Combination drug therapy terazosin 1 mg HS and
  hydrochlorothiazide 12.5 mg AM, warned regarding
  first dose postural hypotensive effect of
  terazosin
• Follow-up BP 132/72 mm Hg standing. Terazosin
  advanced to 2 mg HS with satisfactory symptomatic
  improvement

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Decision to Dropan ALLHAT Arm

• January 24, 2000 NHLBI Director accepts the
  recommendation of an independent review group to
  terminate doxazosin arm
• Futility of finding a significant difference for
  primary outcome
• Statistically significant 25 percent higher rate
  of major secondary endpoint, combined CVD outcomes

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Cardiovascular Disease
doxazosin
Cumulative Event Rate
chlorthalidone
12,990 7,382
9,443 5,285
4,827 2,654
2,010 1,083
Years of Follow-up
C 15,268 D 9,067
JAMA. 20002831967-1975
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Heart Failure
Cumulative Event Rate
doxazosin
chlorthalidone
9,541 5,457
5,531 3,089
2,427 1,351
13,644 7,845
C 15,268 D 9,067
Years of Follow-up
JAMA. 20002831967-1975
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Comparison of Doxazosin with Chlorthalidone -
Conclusions

• Doxazosin is not recommended as first-line
  therapy in hypertension.
• ALLHAT does not allow an assessment of the effect
  of doxazosin compared with placebo on the
  incidence of CVD.
• The use of doxazosin as a step-up drug for
  treating hypertension was not tested in this
  trial.
• These findings are likely to apply to all
  alpha-blockers.

JAMA. 20002831967-1975
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Beta-Blocker and Report of ED