14-1

14
HYPERTENSIVE CRISIS
Those Pills Made Me Sick................. Level I
James J. Nawarskas, PharmD, BCPS

Optimal Plan

CHAPTER 14

Unlike the oral drugs discussed in the previous case, the reasonable options for this patient are limited to IV drugs. An alternative scenario places this patient in a hypertensive urgency and asks the reader to develop an appropriate treatment plan for this situation. There are also several nonpharmacologic treatment options that the reader should recognize. Outcome Evaluation

Hypertensive Crisis

INSTRUCTORS GUIDE TO CHANGES IN THIS EDITION

CASEBOOK Patient Presentation Completely different case: new patient experiencing a hypertensive emergency rather than urgency. Chief complaint involves symptoms of target organ damage; in this case there are three different organ systems being affected by the hypertensive crisis: eyes, peripheral vascular system, and kidneys. This hypertensive crisis was precipitated by a change in the patients antihypertensive regimen. An ACE inhibitor is added to her regimen, and she develops a cough and some dizziness. She becomes frustrated and stops her medications without alerting any health care providers. She then feels better (i.e., the drug side effects go away) and sees no need to resume her medications or seek further medical care. All aspects of the patient case (past medical history, meds, family history, social history, physical exam, etc.) have been modied. Self-Study Assignments Four new self-study assignments added. Clinical Pearl New clinical pearl provided stating that the majority of hypertensive emergencies involve patients already diagnosed with hypertension. INSTRUCTORS GUIDE Problem Identication The reader must determine whether this is a hypertensive urgency or emergency and the cause of this acute condition. This objective is similar to that of the previous case, although this patient is presenting with an emergency as opposed to an urgency. Desired Outcome The treatment goals differ from the case in the previous edition because this patient has a hypertensive emergency. This case also challenges the reader to develop a set of treatment goals and a treatment plan had this patient presented with a hypertensive urgency. Therapeutic Alternatives Unlike the previous case, which emphasized oral antihypertensive therapy for treating a hypertensive emergency, this case focuses on the use of intravenous (IV) agents for treating a hypertensive urgency.

Aggressive BP monitoring and inpatient care are required for this case (vs. less aggressive care for an urgency). Symptom resolution should accompany BP reduction. Patient Education Patient education is a key component of this case, as it should be for all patients with hypertension. This patient was not prepared for the common side effect of cough that not uncommonly will accompany ACE inhibitor therapy, as well as dizziness that is often seen with antihypertensive therapy in general. In addition, she seems to fail to understand the importance of continuing to take antihypertensive therapy. This patient is in need of a variety of educational interventions. To begin, this patient needs to understand the consequences of untreated hypertension and the benets that can be expected with appropriate treatment, not in terms of symptom relief, but in terms of long-term cardiovascular benets. This patient also needs education on the goals of treatment and how she can be more involved with her own well-being by monitoring her own BP and making appropriate lifestyle changes. Finally, all patients should be educated on the common side effects of antihypertensive therapy and should a side effect occur, there are other options available; the side effect often does not need to be tolerated. References Updated to include several recent publications. Some references from the mid-1990s have been retained from the previous case because they provide useful recommendations that are not addressed in any newer references.

CASE SUMMARY
A 61-year-old woman who discontinued her antihypertensive medications about 2 months ago presents to the emergency department with extremely elevated blood pressure and signs and symptoms consistent with target organ damage to her eyes, peripheral arteries, and kidneys. She developed a cough and some dizziness after her primary care provider added an ACE inhibitor to her medication regimen. She stopped taking the medications, and consequently felt better since the drug side effects went away. The patient then concluded that the medications were of no benet and simply stopped taking them. In determining optimal therapy for this patient, the reader must rst determine if this is a hypertensive urgency or hypertensive emergency. The reader must then determine a general course of action, select an appropriate medication regimen (including route), outline monitoring parameters with dened endpoints, and provide a recommendation regarding an appropriate outpatient antihypertensive regimen. In addition, the reader will need to provide detailed educational information to this patient regarding her disease state, the risks and benets of treatment, and the importance
Copyright 2011 by The McGraw-Hill Companies, Inc. All rights reserved.

14-2 of goal setting and behavioral change. Rounding off the case is the recognition of several nonpharmacologic measures for treating hypertension that should be employed in this patient. Hypertensive urgency: Severely elevated BP without acute end-organ damage. Hypertensive emergency: Severely elevated BP associated with acute and ongoing organ damage in the kidneys, brain, heart, eyes, and/or vascular system. Absent in most differentiations between a hypertensive urgency and emergency is a quantication of BP. This is because the distinction between a hypertensive urgency and emergency is based on the presence of acute end-organ damage rather than an absolute BP reading. However, some have proposed that an SBP >220 mm Hg and DBP 120 mm Hg2 or >140 mm Hg3 constitutes a hypertensive emergency. This is based on the belief that most cases of end-organ damage occur with diastolic BP >130 mm Hg.4 Ms Latham has severely elevated BP and, as mentioned above, is exhibiting various signs or symptoms of target organ damage, classifying her case as a hypertensive emergency.

SECTION 2
Cardiovascular Disorders

QUESTIONS
Problem Identication
1.a. Did this patients situation result from a drug-related problem? Why or why not? Yes, although this depends on the denition of drug related. This hypertensive crisis is almost certainly due to nonadherence with the drug regimen. While the pathogenesis of the underlying problem (hypertension) is not drug related, this particular situation (hypertensive crisis) probably would not have occurred had this patient taken her medications as prescribed, and can therefore be categorized as drug related. 1.b. What signs and symptoms are present that may be related to the severity of this patients hypertension? Clearly, the extreme elevations in blood pressure are a sign of severe hypertension. The acute situation is characterized by signs/symptoms of acute target organ damage involving three organ systems: Eyes: Vision difculties and papilledema. Peripheral arteries: Signs/symptoms of intermittent claudication (e.g., absent pedal pulses, shiny skin, leg discomfort). Kidneys: Increased serum creatinine and proteinuria. Of course, without baseline measurements, one cannot be absolutely certain that these are acute changes. However, given her lack of past medical history suggestive of kidney disease, a working assumption that these are acute changes is not unreasonable. Ms Latham is also having some T-wave attening on ECG that may or may not be suggestive of myocardial ischemia, possibly due to an increased workload of the heart, which is trying to pump against an increased afterload, or it may not be an acute change at all. An old ECG would be helpful here for comparison; however, she is not complaining of chest pain. She is also complaining of more frequent headaches, some shortness of breath, and lack of energy. These are nonspecic symptoms that are not pathognomonic of either acute or longstanding hypertension, but the temporal relationship between discontinuation of antihypertensive medications and symptom onset in this case suggests that this is likely more than just coincidence. Ms Latham is also displaying several signs of chronic hypertension: Left ventricular hypertrophy (ECG criteria, lateral displacement of her PMI, enlarged heart on CXR) S4 gallop Funduscopic exam reveals arterial tortuosity and A/V nicking, which is indicative of stage 1 hypertensive retinopathy 1.c. Is this a hypertensive urgency or an emergency? Explain your answer. This is a hypertensive emergency. Hypertensive crises fall under two general categories: hypertensive urgencies and hypertensive emergencies. The JNC 7 complete report denes a hypertensive crisis as a blood pressure >180/120 mm Hg.1 The distinction of a hypertensive urgency from a hypertensive emergency is as follows15:
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Desired Outcome
2.a. What are the goals of pharmacotherapy for this patients hypertension? The immediate goal of therapy is to terminate end-organ damage through BP reduction with IV medications. The degree and rapidity of BP reduction depend on the patient, but BP should not be returned to normal levels right away. An overly aggressive approach that produces too much or too rapid of a reduction in BP may precipitate renal, cerebral, or coronary ischemia because of a sudden drop in perfusion pressure.1 The initial goal is therefore to reduce mean arterial pressure by no more than 25% within minutes to 1 hour and then, if stable, reduce blood pressure to 160/100110 mm Hg within the next 26 hours.1 Alternatively, a reduction in diastolic blood pressure by 1015% or to approximately 110 mm Hg in 3060 minutes is reasonable.6 The long-term goal for this patients hypertension is a BP of less than 130/80 mm Hg, which can occur 12 days after the patient has been stabilized from the acute crisis.1 2.b. How would the treatment goals differ if this patient presented with the same BP but was asymptomatic with normal laboratory ndings and no acute changes on physical examination? Without symptoms or evidence of end-organ damage, this case would be classied as a hypertensive urgency. In this case, treatment need not be as aggressive, and BP may be lowered to desired values over hours to days using oral medications as an outpatient or in a hospital observation room. With hypertensive urgencies, gradual blood pressure reduction is preferred to risking hypotension with aggressive treatment; so a more conservative approach is preferred that incorporates gradual reductions in BP using oral medications.5,7 A gradual reduction in mean arterial pressure of about 25% or a reduction in diastolic BP to 100110 mm Hg is a reasonable goal.7 The goals for managing Ms Lathams chronic hypertension are the same as mentioned above, with a BP goal of less than 130/80 mm Hg.

Therapeutic Alternatives
3.a. What nondrug therapies might be useful for this patient? One nonpharmacologic intervention that has been shown to help is a short period of supine rest in a dark, quiet room. A 1520% decrease in diastolic BP has been seen after 30120 minutes of quiet rest in patients with very severe

14-3 hypertension. However, given the seriousness of the situation, MsLatham will ultimately need drug therapy, and the sooner the better. In addition, the practicality of obtaining a dark, quiet room in a public facility such as a clinic or hospital may be difcult.
8

This patient has the comorbidities of hypothyroidism and newly diagnosed diabetes, which should not pose problems with any of the agents mentioned above. Ms Lathams low heart rate may preclude her from using a -blocker. Clevidipine, esmolol, fenoldopam, and nicardipine have the potential to cost several hundred dollars to administer; the other drugs tend to be less expensive. Of course, costs can be highly variable between institutions. Her acute renal failure necessitates caution with nitroprusside, due to the cyanide and thiocyanate byproducts that form with the metabolism of this drug. However, this can take 68 hours to develop,6 before which the drug may have already done its job and can be discontinued. Both clevidipine and fenoldopam demonstrate BP lowering that is comparable to nitroprusside while avoiding the risks of cyanide and thiocyanate toxicity. These drugs, like nitroprusside, have fast onsets and offsets of effect and are therefore attractive options. However, these drugs cost much more than nitroprusside, which typically limits their usage. The IV antihypertensive drugs and dosages used in the treatment of hypertensive emergencies are listed in Table 14-1. While not directly related to blood pressure management, it should at some point be noted that metformin is currently contraindicated for Ms Latham because of her renal insufciency. It is possible that her kidney function was ne when the metformin was started 3 months ago, and the renal insufciency is acute secondary to her hypertensive emergency. Without knowing her baseline serum creatinine, it is not necessary to discontinue metformin at this time, but perhaps more prudent to hold this drug and repeat a serum creatinine once her blood pressure is under more reasonable control. At that point a more educated decision can be made about whether or not metformin should be continued. 4.b. How would your treatment recommendations differ if this patient presented with the same BP, but was asymptomatic with normal laboratory ndings and no acute changes on physical examination? This would be a hypertensive urgency, and therapy with an oral antihypertensive would be most appropriate for this patient. There are many different oral antihypertensives to choose from, and the choice is largely up to the clinician. In fact, some experts state that the selection of any fast-acting oral drug (e.g., loop diuretics, -blockers, angiotensin-converting enzyme inhibitors, 2 receptor agonists, or calcium antagonists) is acceptable for treating a hypertensive urgency.7 Prazosin, amlodipine, losartan, minoxidil, and nimodipine have also been used effectively for treating hypertensive crises, but the three agents that have the most history of efcacy and safety are captopril, clonidine, and labetalol. These three oral antihypertensives all have a fast onset of action and are relatively short-acting, making them desirable choices for acute but gradual reduction in BP without any long-lasting effects. Sublingual nifedipine, once a popular choice, is no longer considered acceptable for treating hypertensive urgencies due to its unpredictable response and propensity to trigger ischemia due to sudden drops in BP.1 Table 14-2 lists some drugs that have been used in the treatment of hypertensive urgencies. The choice of which of these three agents (i.e., captopril, clonidine, labetalol) to select depends on a variety of factors. They are all easy to administer, inexpensive, and have comparable efcacy, so the clinician must consider patient-specic factors when
Copyright 2011 by The McGraw-Hill Companies, Inc. All rights reserved.

CHAPTER 14

3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of this patients acute hypertension? Parenteral versus oral therapy. The rst determination that should be made is whether Ms Latham should receive IV or oral medications. Due to their quicker onset, parenteral antihypertensives are typically used to treat hypertensive emergencies, whereas oral medications are often acceptable for hypertensive urgencies. However, IV therapy may be considered in any patient who requires the tightly regulated and easily reversible BP reduction not possible with oral agents (e.g., older patients with cardiovascular risk factors or patients with known vascular disease).8 Since this is a hypertensive emergency, IV therapy is warranted. Choice of drug. There are many different IV antihypertensives to choose from, all with similar efcacy, giving the clinician several different pharmacotherapeutic alternatives. Nitroprusside sodium is one of the more commonly used parenteral agents for acute BP reduction because of its efcacy, ease of titration, and relatively low cost. Enalaprilat, esmolol, fenoldopam, hydralazine, labetalol, nicardipine, and nitroglycerin are other IV medications that effectively lower BP in hypertensive emergencies. Clevidipine is a new short-acting dihydropyridine calcium channel blocker with antioxidant properties that is an effective, albeit expensive, option. Diazoxide and trimethaphan camsylate are older agents that are rarely used today. Phentolamine is useful in treating patients with pheochromocytoma. Selection of a specic drug for this patient is addressed in question #4.

Hypertensive Crisis

Optimal Plan
4.a. What drug and dosage form are best for treating this patients acute hypertension? Based on the previous answer, therapy with an IV antihypertensive would be most appropriate for this patient. As discussed earlier, the clinician has a fairly large armamentarium of drugs to choose from when selecting an appropriate IV antihypertensive. These include clevidipine, enalaprilat, esmolol, fenoldopam, hydralazine, labetalol, nicardipine, nitroglycerin, and nitroprusside. Older agents such as diazoxide and trimethaphan camsylate are rarely used, and phentolamine is useful primarily in treating patients with pheochromocytoma. As with most cases of hypertension, multiple factors should be considered when selecting an appropriate antihypertensive agent. These include, but are not limited to, the efcacy of the drug in the presence of a specic patient comorbidity, drug cost, drug safety, onset/offset of effect, and ease of administration. While all of these agents act quickly (all within 10 minutes with the exceptions of enalaprilat and hydralazine that may take 30 minutes), clevidipine, nitroprusside, esmolol, nitroglycerin, and fenoldopam have the added advantage over other agents of possessing a short duration of action (less than 30 minutes), enabling rapid down-titration if blood pressure reduction occurs too quickly.

14-4 TABLe 14-1 Intravenous Medications Used in the Treatment of Hypertensive Emergencies1
Dose 12 mg/h to start, titrate as needed to maximum of 32 mg/h 1.255 mg Q 6 h 250500 mcg/kg/min bolus given over 1min, and then 50100 mcg/kg/min for 4min; may repeat sequence and increase infusion rate stepwise by 50 mcg/kg/min up to a maximum of 300 mcg/kg/min 0.10.3 mcg/kg/min 1020 mg bolus 0.52.0 mg/min 515 mg/h 5100 mcg/min 0.2510 mcg/kg/min Onset 24 min 1530 min 12 min Duration 515 min 612 h 1030 min Comments May cause reex tachycardia Active moiety of enalapril; useful for heart failure; avoid in acute myocardial infarction Avoid in acute heart failure

SECTION 2
Cardiovascular Disorders

Drug Clevidipine Enalaprilat Esmolol

Fenoldopam Hydralazine Labetalol Nicardipine Nitroglycerin Sodium nitroprusside

<5 min 1020 min 510 min 510 min 25 min Immediate

30 min 14 h 36 h 1530 min, may exceed 4 h 510 min 12 min

Dopamine agonist; effective but expensive; safe with renal impairment Typically reserved for eclampsia Avoid in acute heart failure Avoid in acute heart failure; caution with coronary ischemia Useful for coronary ischemia Direct vasodilator; rst-line agent for most situations; thiocyanate and cyanide byproducts may cause toxicity, especially with renal dysfunction

deciding which drug to recommend. In the case of Ms Latham, she was just recently started on lisinopril and complained of dizziness, so there is reason to believe that ACE inhibitors (i.e., captopril) may be effective for her. Also, her low heart rate may lean the provider away from using labetalol. In the end, the reader should understand that each of these treatments may be acceptable with proper consideration of patient-specic characteristics. Ms Latham has the comorbidities of hypothyroidism and newly diagnosed diabetes, which should not pose problems with any of the agents in Table 14-2.

Ms Latham should be frequently queried regarding any improvement in vision and leg discomfort. Respiratory rate should be monitored and assessed at least every 46 hours by whatever means are available (e.g., via monitor, visual observation, or auscultation). Funduscopic examinations should be performed at least daily during the patients hospitalization in order to monitor for improvement in the acute ocular changes that were present on admission. While the papilledema should resolve fairly quickly with appropriate therapy, the retinal changes that occur with chronic hypertension will not. Pedal pulses should be palpated every 68 hours until they are palpable, and then daily thereafter. A repeat BUN and serum creatinine should be performed several hours after the initiation of antihypertensive therapy and at least daily thereafter. A repeat urine sample should be performed at some point to reevaluate the proteinuria that was present on admission. This may be performed during the patients hospital stay or as an outpatient, keeping in mind that proteinuria may take several weeks to resolve. A repeat 12-lead ECG should also be performed within the rst 24 hours of hospitalization to follow up on the T-wave attening that was present on admission. Ms Latham should also be instructed to report any feelings of dizziness, light headedness, nausea, or worsening headache,

Outcome Evaluation
5. What clinical and laboratory parameters are necessary to evaluate your therapy for reducing this patients BP and monitoring for adverse events? Regardless of the drug chosen, BP and heart rate are the primary clinical endpoints and should be continually obtained with intra-arterial monitoring until symptoms resolve. Areduction of diastolic BP by 1015% or to about 110 mm Hg in 3060 minutes is reasonable for this patient as is a reduction in mean arterial BP of not more than 25% within minutes to 2 hours, and then toward 160/100 mm Hg within 26 hours.1,6 In patients with acute aortic dissection, achievement of this goal in 510 minutes is recommended.2 The immediate goal of antihypertensive therapy is to alleviate the signs and symptoms of target organ damage. Therefore,

TABLe 14-2
Drug Amlodipine Captopril Clonidine Labetalol Prazosin

Oral Drugs Used in the Treatment of Hypertensive Urgencies35,9

Dose 510 mg 12.525 mg, may repeat in 12 h 0.10.2 mg, and then 0.1 mg every hour asneeded up to 0.6 mg total 200400 mg, may repeat every 23 h 12 mg Onset 3050 min 1530 min 30120 min 30120 min 24 hours Duration Up to 24 h 46 h 68 h 36 h 710 h Comments May cause headache, tachycardia, and/or peripheral edema Typically acts quicker than clonidine or labetalol May reduce heart rate; use of 0.2 mg initial dose is questionable May reduce heart rate May cause syncope, tachycardia, and postural hypotension

Copyright 2011 by The McGraw-Hill Companies, Inc. All rights reserved.

14-5 which are common side effects of any of the antihypertensive drugs. If nitroprusside is selected, then monitoring plasma cyanide and thiocyanate concentrations may be an issue, depending on how long the drug is given. Some experts believe that cyanide toxicity may occur as early as 68 hours after the infusion is started.6 Sodium thiosulfate (1 g per 100 mg nitroprusside) is often given in conjunction with nitroprusside in order to detoxify the cyanide that is generated by this drug. The primary signs and symptoms of cyanide/thiocyanate toxicity are confusion, lethargy, headaches, disorientation, and metabolic acidosis. Current methods of monitoring for cyanide/thiocyanate toxicity are thought to be largely inadequate, although periodic monitoring of plasma thiocyanate concentrations (goal <10 mg/dL) has been advocated in patients receiving nitroprusside infusions for greater than 24 hours and in patients with renal insufciency (as in this patient).5 Many factors contribute to poor adherence with antihypertensive drug therapy1: Misunderstanding of the condition or treatment Denial of illness because of lack of symptoms Perception of drugs as symbols of ill health Lack of patient involvement in the care plan Unexpected adverse effects of medications With thorough patient education many of these factors can be controlled. Lifestyle modications would also help Ms Latham ensure the success of her therapy. This will be discussed below. Hypertensive Crisis

CHAPTER 14

Clinical Course
Once Ms Lathams blood pressure is lowered to an acceptable level, her inpatient provider consults with you regarding chronic antihypertensive therapy for Ms Latham. 7.a. Do you recommend Ms Latham resume her lisinopril and HCTZ as prescribed or would you recommend alternative drug therapy? Rationalize your answer. If you would recommend alternative drug therapy, which drug(s) would you recommend and why? It would probably be best that Ms Latham not be on an ACE inhibitor at this time. While ACE inhibitors are rst-line antihypertensives for patients with diabetes, she developed a cough that was likely due to the lisinopril. She does not need to tolerate the cough as there are other options that are just as effective without this adverse effect. The thiazide diuretic is probably a good choice as this is a recommended add-on drug per JNC-7 as well as American Diabetes Association guidelines. Whether chlorthalidone or hydrochlorothiazide is prescribed is a matter of personal preference. Ms Latham was on chlorthalidone in the past with good success, but this thiazide is not commonly available in combination products, so if she were to be on it and another drug, she would likely have to take two different tablets, thereby adding to her pill burden. It is also unclear as to what Ms Lathams blood pressure control was like as an outpatient. What we do know is that it was under reasonable control with chlorthalidone, and her primary care provider was compelled to be more aggressive once a diagnosis of diabetes was made about 3 months ago. We are therefore left to believe that Ms Latham was not at her goal blood pressure of <130/80 mm Hg, which led to the addition of the ACE inhibitor. While it would be nice to know what her outpatient readings were, we will need to make do with the information we have and proceed with dual drug therapy under the assumption that her blood pressure was above 130/80 mm Hg while on thiazide diuretic monotherapy. This is not an unreasonable assumption, as most patients with diabetes require at least two antihypertensives to reach their blood pressure goal. The logical (and recommended) alternative to the ACE inhibitor is an angiotensin receptor antagonist. This choice is supported by both the American Diabetes Association and JNC 7 guidelines. Switching from an ACE inhibitor to an angiotensin receptor antagonist is felt to be a lateral move in terms of efcacy and will in all probability eliminate the cough. This is therefore the easy choice for Ms Latham, provided that cost is not an issue (below). The choice of which angiotensin receptor antagonist to prescribe is most often driven by cost and formulary restrictions.
Copyright 2011 by The McGraw-Hill Companies, Inc. All rights reserved.

Patient Education
6. What information can you provide to Ms Latham to enhance adherence, ensure successful therapy, and minimize adverse effects? There are two main reasons why Ms Latham suffered a hypertensive crisis: (1) lack of understanding about her disease state and (2) lack of understanding about medication-related side effects. Both of these issues need to be discussed with Ms Latham in order to optimize therapeutic success. It is apparent that Ms Latham does not understand her disease state. A patient-centered strategy is crucial for success in improving medication adherence with antihypertensives. Patient-centered behavioral interventions such as counseling have been shown to increase BP control.1 Behavioral models suggest that the best therapy prescribed by the best clinician will only control hypertension if the patient is motivated to take his or her medication and to establish and maintain a health-promoting lifestyle.1 Patients with hypertension should be made aware of their BP goals and encouraged to take a leading role in getting themselves to this goal.1 Ahome BP monitoring device would assist in this regard. Ms Latham should know what hypertension is and understand the consequences of untreated hypertension (e.g., heart disease and stroke) and the benets of well-treated hypertension, for example, 3540% reduction in stroke, 2025% reduction in myocardial infarction, and over 50% reduction in heart failure rates.1 In the end, patients who believe they need to take antihypertensive medication are more likely to take this medication.10 The adverse effects of antihypertensive medications should also be made known to Ms Latham in order to minimize surprise and upset should an adverse event occur. Patients should also understand that if one drug does not work or is not tolerated, there are many other options available and that medicationrelated adverse effects do not need to be tolerated. Critical to minimizing medication-related adverse effects is an open line of communication between patient and provider. It is the providers responsibility to inform the patient of common medication-related adverse events and to ensure the patient that should an adverse event occur, an appropriate modication in therapy will be performed. It is also the patients responsibility to relay any suspicious or unusual symptoms to the provider, as this may represent a medication-related adverse effect. In Ms Lathams case, this breakdown in communication was likely responsible for her hypertensive crisis.

14-6 TABLe 14-3 Nonpharmacologic means of lowering blood pressure1

Recommendation Maintain normal body weight (BMI 18.524.9 kg/m2) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce dietary sodium intake to no more than 2.4 g Engage in regular aerobic physical activity such as brisk walking (atleast 30 min per day, most days of the week) Limit consumption to no more than two drinks (1 oz ethanol, e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons Stop smoking Approximate SBP Reduction 520 mm Hg/10-kg weight loss 814 mm Hg 28 mm Hg 49 mm Hg 24 mm Hg

SECTION 2
Cardiovascular Disorders
a

Modication Weight reduction Adopt DASH eating plana Dietary sodium restriction Physical activity Moderation of alcohol consumption

Smoking cessation

Depends on volume of cigarettes smoked and duration; average SBP reduction is about 4 mm Hg; SBP has been shown to be increased by about 10 mm Hg for up to an hour after smoking

DASH, Dietary Approaches to Stop Hypertension (diet rich in potassium and calcium).

7.b. What economic considerations are applicable to this patient regarding drug selection? As mentioned above, an angiotensin receptor antagonist is the preferred option for Ms Latham in lieu of an ACE inhibitor. However, these medications are considerably more expensive than most ACE inhibitors; only losartan is available as a generic and even this is rather costly. In consideration of this, most third-party payors have restrictions on the prescribing of these medications, although there typically are provisions that will allow for prescription coverage of these agents in the event of documented ACE inhibitor intolerance, as is seen with Ms Latham. It is therefore reassuring that Ms Latham has prescription drug coverage, although it is the responsibility of the provider to nd out which angiotensin receptor antagonists are covered by their patients prescription plans to minimize any frustration and surprise that may occur should a patient go to pay for a medication not covered by his or her insurance plan. In the event of lack of prescription coverage for a given patient, any of the brand name angiotensin receptor antagonists would be expected to cost in excess of $100 per month, with generic losartan costing about $50 per month, making these options often impractical for a patient with nancial constraints. In these situations, -blockers or calcium channel blockers are recommended.1 7.c. What nonpharmacologic measures can Ms Latham incorporate as part of an overall treatment plan for her chronic hypertension? Ms Latham has much room for improvement in terms of her lifestyle in order to optimize therapeutic outcomes for her blood pressure control: She does not exercise and leads a rather sedentary lifestyle. She smokes cigarettes. She ingests a lot of sodium, in both the foods that she eats

(cold cuts, canned vegetables) and the extra salt she puts on her food after it is prepared. Her diet needs improvement (in particular the snack cakes and chips she consumes while at work). She is overweight. She uses ibuprofen frequently. Table 14-3 lists common lifestyle interventions that should be employed by all patients with hypertension.

REFERENCES
1. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42: 12061252. 2. Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev 2010;18:102107. 3. Hebert CJ, Vidt DG. Hypertensive crises. Prim Care Ofce Pract 2008;35:475487. 4. Varon J, Marik PE. The diagnosis and management of hypertensive crises. Chest 2000;118:214227. 5. Mansoor GA, Frishman WH. Comprehensive management of hypertensive emergencies and urgencies. Heart Dis 2002;4:358371. 6. Varon J. Treatment of acute severe hypertension. Current and newer agents. Drugs 2008;68:283297. 7. Aggarwal M, Khan I. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin 2006;24:135146. 8. Thach AM, Schultz PJ. Nonemergent hypertension. New perspectives for the emergency medicine physician. Emerg Med Clin North Am 1995;13:10091035. 9. Gales MA. Oral antihypertensives for hypertensive urgencies. Ann Pharmacother 1994;28:274284. 10. Ross S, Walker A, MacLeod MJ. Patient compliance in hypertension: role of illness perceptions and treatment beliefs. J Hum Hypertens 2004;18:607613.

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