Cvs problem solving exercises

1. CVS clinical problems 2

2. • Patient L., is a 76‐year‐old woman. She complains
about high ВР (up to 200/55 mmHg) and,
consequently, bad state of health, vertigo,
weakness and sometimes insomnia.
• She has been noticing BP over 140/90 mmHg
since the age of 40, when she first measured her
BP because of severe headache.
• ISH was diagnosed at the age of 70 but the
patient does not take constant therapy. If SBP
raises over 200 mmHg, she takes 10 mg of
nifedipine SR.
• Gout was diagnosed at the age of 74. At present,
the level of uric acid is normal, and the patient
does not take any drugs.

3. • She works 3 days a week and it should be noted
that it takes her to walk 500 m and 40 minutes
by public transport (usually standing) to get to
work.
• At a health camp, her ВР was 186/62 mmHg.
• According to the ECG data, amplitude criteria of
left atrial enlargement (without repolarization
defects) are present, as a result of high BP; heart
rate is 61 bpm. CBC (FBC), blood test and urine
test were unremarkable.
• Osler's test is negative. The MMPI and the
Schulte table questionnaire did not reveal any
deviations.

4. • Q-1.
What is Isolated systolic hypertension?
ВР readings are > 130 <80
Most common form of high BP in people older than
age 65. younger people also might be affected. ISH
can be caused by underlying conditions such as
artery stiffness, hyperthyroidism, diabetes, aortic
valvular disease etc.

5. • Q-2
What is the target BP?
the recommended BP target is <150 mm Hg
systolic. However, strict BP control may not
enhance the clinical benefit in the prevention of
cardiovascular events as compared with that of
moderate BP control.

6. Q-3
Which drug can be used for initial therapy?
Diuretics and CCBs are initial choice in ISH.
This patient has Gout. Diuretics increase uric
acid level dose dependently. Hence avoided.
Patient has atrial enlargement. Hence an ARB is
preferred for initiation. They have favorable
effect on heart remodeling.
Valsartan is given 40mg once daily. If the target
BP is not achieved within a month, the dose of
valsartan is increased by 40mg upto 160 mg.

7. • Q-4: What if the BP is not controlled with
monotherapy?
CCBs are safe in gout. Amlodipine can be started with
2.5mg once daily and increased by 2.5mg upto 10mg
per day.
Q-5: What special precautions are to be taken while
giving antihypertensive medications in this age group?
• To avoid reduction in diastolic BP which is required
for adequate perfusion of vital organs like heart,
kidneys and brain
• To prevent orthostatic hypotension. That causes a fall
which may end up with fracture hip and mortality
soon.

8. • Q-4: How to detect orthostatic hypotension?
• Have the patient lie supine for 10 minutes and
obtain blood pressure and HR. ...
• Take blood pressure and HR immediately after
the patient arises and ask about dizziness.(light
headedness)
• After the patient maintains an upright posture
for 5 minutes, obtain blood pressure and HR
again. Fall of 20 systolic or 10 diastolic is
considered postural hypotension

9. • R.R. is a 52-year-old man with hypertension for 10
years.
• He has not yet experienced any hypertension-
associated complications or target-organ damage.
• He does not have a history of diabetes and does
not smoke.
• He has been treated with HCTZ 25 mg daily,
amlodipine 10 mg daily, valsartan 320 mg daily,
and carvedilol 12.5 mg twice daily for 1 year.
• He reports rarely missing a dose of his
medications, measures his BP at home every day,
and follows recommended lifestyle modifications
as diligently as possible.

10. • He has tried other medications that resulted
in intolerances (doxazosin, dizziness;
clonidine, dry mouth).
• His BP has never been less than 140/90 mm
Hg, which is his goal.
• His BP today is 150/90 mm Hg (152/92 mm
Hg when repeated), his heart rate is 60
beats/minute, serum potassium is 4.2 mEq/L,
and serum creatinine is 1.0 mg/dL. He is 163
cm tall and weighs 68 kg.

11. • Q1. Does R.R. have resistant hypertension? What
are his treatment options?
• Resistance hypertension is defined as BP ≥ 140/90
mm Hg on ≥3 antihypertensive drugs of different
classes including one diuretic at optimal doses, or
<140/90 on ≥4 drugs
• He has resistant hypertension on first criteria.
• R.R is on maximal doses of valsartan and amlodipine.
Carvedilol can be increased to 25mg twice daily, but
heart beat is already 60bpm.
• Sometimes a change from HCTZ to chlorthalidone
50mg OD (max 100mg) may be more effective.
• Frusemide, spironolactone and hydralazine
completes the spectrum of choices.

12. • However secondary causes of hypertension is
to be diagnosed. He may be referred to a
hypertension specialist.
• List some causes of secondary hypertension
- Drugs eg NSAIDs, nasal decongestants,
cyclosporine, erythropoietin, OC Pills
- Drug abuse eg cocaine, amphetamine,
ephedrine,
- Diseases: endocrine: hyperaldosteronism,
cushings, acromegaly, phaeochromocytoma,
hyperthyroidism etc

13. • Vascular anomalies like coarctation of aorta,
renal artery stenosis
• Kidney diseases
• Renin secreting tumours
• Genetic: Liddle syndrome; dysregulation of
the epithelial sodium channel (ENaC)
• pseudo-resistant hypertension that results
from non-adherence to medications, artery
stiffness etc
• If drugs fail to correct BP, what next?
Surgery: Renal artery denervation: exclude
artery stiffness, secondary causes carefully