A 48-year-old Caucasian man with impaired fasting glucose presents to his physician for a follow-up visit after he was noted to have a blood pressure of 150/95 mmHg. On repeat evaluation his blood pressure is 155/95 mmHg.
Which of the following medications would be the least favored?
Atenolol 25 mg PO daily. The least effective option is atenolol. The ALLHAT study showed that the use of thiazide diuretics as first-line therapy for treatment of uncomplicated hypertension was as effective as, if not superior to, amlodipine and lisinopril in preventing fatal coronary artery disease and nonfatal myocardial infarction. The choice of an ACEI would be reasonable, given the presence of glucose intolerance. β-Blockers would not be indicated as first-line therapy in this patient. Multiple meta-analysis comparing β-blockers with placebo or other antihypertensive agents have shown no statistically significant decreases in mortality, myocardial infarction, and stroke. The Anglo Scandinavian Cardiac Outcomes Trial (ASCOT) trial comparing atenolol with amlodipine found a 23% greater risk of stroke in the atenolol group versus the amlodipine-based regimen.
A 65-year-old African American man with isolated hypertension presents to clinic for his yearly physical examination. He is noted to have a blood pressure of 170/95 mmHg. He is currently prescribed lisinopril and metoprolol.
Which of the following medication changes would be most appropriate?
Conversion of patient to a calcium channel blocker and thiazide diuretic. Analysis of the clinical trials in hypertension has noted that there are differences in the effectiveness of antihypertensive medications between different ethnic groups. African Americans are more responsive to calcium channel blockers and thiazide diuretics than other antihypertensive agents. This patient is on an ACEI and a β-blocker. Altering his regimen to include more effective antihypertensive agents would be indicated rather than increasing his medications, adding additional medications, or evaluating him for secondary causes of hypertension. The new JNC 8 guidelines make recommendation of medication based on the race of the patient.
A 42-year-old woman with a new diagnosis of diabetes mellitus presents for management of hypertension. She was previously an avid athlete, but over the past few years has noted increased weight gain, a radial fracture after a minor fall, and increasing hirsutism. She is currently on hydrochlorothiazide, amlodipine, and lisinopril.
What is the most appropriate next step in the management of this patient’s hypertension?
24-Hour urine cortisol test. This patient’s medical history is consistent with a secondary cause of hypertension, in particular, Cushing syndrome. This syndrome is characterized by an excess of cortisol. It may be secondary to a pituitary tumor/hyperplasia (Cushing disease), an adrenal tumor, or ectopic adrenocorticotropic production. Clinical manifestations include diabetes mellitus, hypertension, obesity, hypokalemia, osteoporosis, and fungal infections. The initial step in diagnosis is a 24-hour urine free cortisol test. Treatment is surgical.
A 69-year-old woman with diabetes mellitus and hyperlipidemia and no history of hypertension is noted at her yearly clinic visit to have new-onset hypertension with a blood pressure of 180/110 mmHg. She undergoes screening for secondary causes of hypertension and is found to have a pheochromocytoma.
What of the following medications is contraindicated as monotherapy?
Metoprolol. Pheochromocytoma is a rare cause of hypertension. Treatment ultimately requires surgical removal. The use of β-blocker monotherapy is contraindicated as part of the medical management of pheochromocytomas. The catecholamines secreted by these tumors activate both peripheral α- and β-receptors. Blockage of these peripheral β-receptors results in unopposed α-activation. This can result in severe hypertension. Typical medical management of pheochromocytomas involves the use of antihypertensives with α-blocking capability. For example, prazosin or phenoxybenzamine may be used. Only once α-blockade is established should the use of a βblocker be entertained.
A 42-year-old man presents for a routine physical examination. He is noted to have a body mass index of 30 kg/m2 , impaired fasting glucose, and a blood pressure of 135/85 mmHg.
What is the best treatment plan for this individual?
Aggressive lifestyle modification. Patients with prehypertension are at increased risk for cardiovascular events compared with normotensive individuals; therefore, care of these patients should be focused on aggressive control of all cardiovascular risk factors. Analysis of the Women’s Health Initiative compared cardiovascular outcomes in prehypertension patients with normotensive patients and found that the prehypertension patients had hazard ratios indicating a 1.58 (95% confidence interval [CI], 1.12 to 2.21) greater risk for cardiovascular death; 1.76 (95% CI, 1.40 to 2.22) greater risk for myocardial infarction; 1.93 (95% CI, 1.49 to 2.50) greater risk for stroke; 1.36 (95% CI, 1.05 to 1.77) greater risk for hospitalized heart failure; and a 1.66 (95% CI, 1.44 to 1.92) greater risk for any cardiovascular event. Not only are these patients at increased risk for cardiovascular events, but they also have a high incidence of hypertension development. In the Trial of Preventing Hypertension (TROPHY) trial, patients with prehypertension were randomized to candesartan or placebo. Over a period of 4 years, 67% of the untreated group developed hypertension as defined by the JNC 7 guidelines. These data suggest that patients with prehypertension are a highrisk population and should be treated aggressively. According to the JNC 7 guidelines, these individuals should increase their activity level, modify their diet, avoid excessive alcohol, and attempt weight loss. Initiation of antihypertensive medications should be reserved for those who progress to evident hypertension.
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