Cardiology

PCP submission

60 y/o M known for hypertension that has been uncontrolled for the past year- despite patient being adherent to his meds.

Asymptomatic- no chest pain, no SOB, no palpitations.

Morning readings consistently show BPs of 165/95 going down to 135/85 midday (readings are similar on both arms.) Patient was diagnosed with HTN 6 years ago and has been taking the regimen below. Has undergone stress test and nuclear scan in the past that were normal.

PE: BMI 28.1; HR: in the 50s (known for bradycardia since childhood).

Labs: Routine labs done annually and normal, including lipid profile and thyroid.

Meds:
-Allopurinol 300mg qam (for gout)
-Doxazocin 4mg qam and qhs
-Losartan 25mg qhs
-Metoprolol 25mg qam (prescribed by a cardiologist years ago for “benign arrhythmia” with “skipped beats”; completed workup above that came back normal; no EKG available)
-ASA low dose

PMHx: unremarkable (appendectomy, upper extremity ligament repair)

FHx: hypertension, brother has CAD, no sudden death, no stroke

Allergies: sensitivity to codeine

Social Hx: no smoking/drinking/drugs

What medication adjustments would you recommend for this patient?

Specialist response

Hi, thanks very much for the question. It sounds like your patient has a long standing history of primary essential hypertension, but has suboptimal blood pressure control throughout the day as well as in the early morning. In a situation like this, if medication changes are deemed necessary, I would begin by increasing the nightly dose of losartan every week until blood pressure control has improved. As you know, current ACC/AHA guidelines recommend treatment of hypertension to a target blood pressure of <130/80 mmHg, which your patient’s midday readings are above. (Whelton et al. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13–e115). At 165/95, morning blood pressure readings seem to be well above the 135/85 midday measurement that your patient is obtaining. These morning surges in blood pressure are a well described phenomenon that can be physiologic, but the degree to which these surges are present in your patient suggest an exaggerated morning blood pressure surge. Given the findings of the midday readings, it seems that your patient does truly need an escalation in the dosing of anti-hypertensive therapy. The consensus on how best to approach morning surges in blood pressure, even when exaggerated, is however not as well established, with part of the reason being that trials have not rigorously evaluated whether or not selective treatment of these surges alone result in lower rates of end-organ dysfunction from hypertension. This said, when morning surges are treated in patients with established hypertension, targeting the goals set forth in the ACC/AHA guidelines for all measurements results in better 24-hour blood pressure control from a practical standpoint. Generally speaking patients with morning surges are best treated with agents including calcium channel blockers, alpha blockers, or ace inhibitors/arb, with nightly dosing (Kario, K. Morning Surge in Blood Pressure and Cardiovascular Risk. Hypertension. 2010;56(5):765-773). Your patient is receiving two of these classes with doxazosin and losartan nightly, however there is room for titration of losartan to a higher dose. I would generally begin my maximizing the dose of losartan, first to 50mg qhs, and if blood pressure remains elevated I would increase it further to 100mg qhs, a dose that is often necessary in a large fraction of hypertensive patients. In addition, and potentially prior to the medication adjustment, it’s of course important to take all efforts to ensure as much as possible that the patient is indeed compliant with current medications and that blood pressure measurements are accurate. As you may have done, I suggest confirming that patients are indeed accurately checking there blood pressure, that is, after being seated for a 5-minute period. Likely similar to what this patient is doing, I have patients check their pressure at least 3-5 days a week and maintain a log. I also have patients collect two back to back measurements and I average them, which helps me to identify and exclude readings that may be obviously spurious. It seems like your patient is likely doing much of this already. As a final points, it is always also worth confirming that the patient does not have excess sodium intake in their diet from processed food, that they are not drinking excessive alcohol or coffee, and that they are not taking NSAIDs frequently. As we know, these are all not infrequent contributors to hypertension and there is good data in guidelines that screening for these contributors improve outcomes. (See: Carey et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension. 2018;72(5):e53-90). It is also worth reviewing screening questions related to sleep apnea (loud snoring, daytime somnolence), if this has not already been done. Presuming readings are accurate, and no contributing lifestyle or modifiable factors are present, I would anticipate improvement in blood pressure with incremental increase in the dose of losartan as described above. If at the maximal dose of losartan, hypertension persists above target blood pressure, I would consider discontinuation of metoprolol given its uncertain benefit, and substitution with amlodipine (or other dihydropyridine CCB) given that it comparatively has higher efficacy when treating hypertension.

PCP follow up

Thanks so much- this is really helpful! What are your thoughts on adding HCTZ 25mg? Given that metoprolol was originally prescribed for an “arrhythmia” rather than hypertension- would you still recommend considering its discontinuation as you recommended in your algorithm above?

Specialist follow up

I would first focus on maximizing losartan. If losartan at max dose doesn’t get blood pressure sufficiently controlled then rather than adding a new medication, my thought was that substituting metoprolol for a better anti-hypertensive may be preferred. My reasoning was that, based on the history, the use of an every day medication (metoprolol 25mg qd) for a benign (and potentially infrequent) arrhythmia vs skipped beats, seemed unclear. If the patients symptoms related to this arrhythmia were very frequent and bothersome prior to metoprolol then it may be worth keeping on. If they were not very frequent or bothersome, then I would revisit this issue, and consider discontinuing metoprolol (when adding a different agent, to keep total number of medications the same) and seeing if any symptoms related to this recur. As an alternative to amlodipine, hydrochlorothiazide is also a very effective anti-hypertensive. My only concern is that there is some data that suggests that its less effective when used in patients with exaggerated morning surges in blood pressure, in part due to a nocturnal dip in blood pressure with diuretics, which may perpetuate the morning surge. (See: Kimura G. Kidney and circadian blood pressure rhythm. Hypertension. 2008;51: 827–828)