Clinical Case Studies

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

 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.
 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 > 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.

 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.
 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

What is Hypertensive Urgency?

Higher levels of Stage 2 hypertension with headache,
shortness of breath, anxiety, epistaxis; no Target Organ
Damage (TOD)
Am I going to stroke out?
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
 Mean Arterial BPs in
Three Treatment Groups, mm Hg
 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
 HTN algorithm: Triage

• BP>180/110;
h/a, anxiety, asx; exam: no TOD Observe 1hr; initiate,
resume, increase med; follow-up within 3 days

• BP>180/110;
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

>220/140: to ICU
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
 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
 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”)
 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
 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.
 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.
 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.
SBP Reduction: Monotherapy ACEI Advance
Vs Combination therapy with HCTZ
 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.
 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
ALLHAT Decision to Drop
an 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
 Cardiovascular Disease
0.30 Rel Risk 95% CI
ALLHAT
1.25 1.17-1.33
Cumulative Event Rate

0.25
z = 6.77, p < 0.0001
0.20
doxazosin
0.15

0.10 chlorthalidone

0.05
12,990 9,443 4,827 2,010
7,382 5,285 2,654 1,083
0.00
0 1 2 3 4
C: 15,268 Years of Follow-up
D: 9,067 JAMA. 2000;283:1967-1975
 Heart Failure
0.10 Rel Risk 95% CI
ALLHAT
2.04 1.79-2.32
Cumulative Event Rate

0.08
z = 10.95, p < 0.0001

0.06

doxazosin
0.04 chlorthalidone

0.02
9,541 5,531 2,427
5,457 3,089 1,351
0.00 13,644
7,845
0 1 2 3 4
C: 15,268
D: 9,067
Years of Follow-up
JAMA. 2000;283:1967-1975
 Comparison of Doxazosin with
ALLHAT
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. 2000;283:1967-1975
Beta-Blocker and Report of ED