Chapter 16, Drugs Affecting the Cardiovascular and Renal Systems

Instructor Case Study

History
Ms. DA is a 42-year-old mildly obese black female who presents to you to establish care. She
has been without health insurance for quite some time, and has only recently been covered
through her employment. However, her insurance only covers 50% of the cost of any
prescription medications. She has no complaints today, and is feeling well. Her last menstrual
period (LMP) was 2 weeks ago. Past medical history is significant only for migraine headaches
and a tubal ligation approximately 8 years ago. She does state that many of her first degree
relatives have hypertension (HTN) and type 2 diabetes, and that her mother and an older sister
had heart attacks when they were in their 50s. The patient, herself, has no cardiac history. She
takes no medications except Excedrin Migraine as needed for her headaches. She does not
smoke, drink alcohol, or use recreational drugs.
Assessment
Physical exam: Well-developed, well-nourished, mildly obese African American female in
NAD. Ht: 65 in., Wt: 185 lb. Blood pressure (BP) is 152/84, heart rate (HR) is 76, respiratory
rate (RR) is 18, and temperature is 98.8F orally. Neck is without jugular venous distention
(JVD) or carotid bruits. Lungs are clear to auscultation bilaterally. Cor: nl s1s2, rrr, without rubs
or gallops. A grade 2/6 harsh, blowing systolic murmur is heard across the precordium.
Abdomen examination shows active bowel tones, no bruits, nontender, and no organomegaly.
Extremities are without clubbing, cyanosis or edema. She has not had any recent screening blood
tests.

Your preliminary diagnoses are:

1. Blood pressure elevation, with no prior readings for comparison
2. Obesity (body mass index [BMI] is 30.8)
3. Systolic murmur, likely aortic stenosis
4. Family history of early coronary artery disease
5. Multiple risk factors for coronary artery disease.
The patient so far has at least two coronary risk factors (obesity and positive family
history of early coronary disease), and may have others (likely HTN, and possibly type 2
diabetes and hyperlipidemia or dyslipidemia).
Initial Management Plan
1. You decide to order screening labs, which include a fasting blood sugar, fasting lipids,
liver profile (in the event that the patients requires lipid management or an angiotensin
receptor blocker (ARB) is needed), thyroid-stimulating hormone (TSH, which can effect
lipid metabolism), electrolytes, blood urea nitrogen (BUN), creatinine (in the event that
an angiotensin-converting enzyme [ACE] inhibitor is needed), and a complete blood
count (CBC).
2. You decide to order a screening transthoracic echocardiogram to assess the murmur. New
or previously undiagnosed murmurs should be assessed, especially systolic murmurs,
prior to any exercise stress testing (which is not indicated at this time). Stress tests are
ordered for symptoms, not for screening of asymptomatic patients, even with a family
history of coronary disease or in the presence of several cardiac risk factors.
3. The patient should return for two more blood pressure readings on two other occasions,
before a diagnosis of hypertension can be made.

4. The patient may have knowledge deficits regarding a healthy lifestyle. This should be
assessed, and the patient should be educated regarding the need for adequate exercise,
and following a diet low in cholesterol, saturated fats, salt, and refined sugars. The patient
may need education regarding stress management.
5. You decide to see the patient back in 2 weeks to discuss the results of the blood pressure
screenings, the laboratory tests, and the transthoracic echocardiogram.
Follow-Up Visit
The patients BP today is 148/84 and HR is 76. Readings 1 week ago were 156/90 and 72. She
has no complaints. Her screening echocardiogram showed mild aortic stenosis, normal left
ventricular size and functioning, and no focal wall motion abnormalities. The fasting blood sugar
was 87, total cholesterol was 225, triglycerides were 175, low-density lipoprotein (LDL) was
172, and high-density lipoprotein (HDL) was 44. alanine aminotransferase (ALT) was 27, and
aspartate aminotransferase (AST) was 29. TSH was 1.62. Sodium was 140, potassium was 4.4,
BUN was 18, and creatinine was 0.9. White blood cells (WBCs) were 5.5, hemoglobin (Hgb)
was 12.5, hematocrit (Hct) was 36.2, and platelets were 340.
Modifications of Treatment Plan
1. The patients three blood pressure readings indicate the need for the initiation of
antihypertensive medication. She has stage I HTN. Prescribing an ACE inhibitor is not
contraindicated in this premenopausal female, because she has had a tubal ligation and
therefore, has no potential for pregnancy; however, you know that African American and
Asian patients have a higher risk for angioedema with this class of antihypertensives than
do white patients. A thiazide diuretic would be a reasonable first-line treatment,
especially in an African American and obese patient. Moreover, thiazide diuretics are

inexpensive, especially in generic forms. You decide to start to start her on

hydrochlorothiazide (HCTZ) 12.5 mg PO daily. You draw serum magnesium and uric
acid levels today before she leaves the office, as diuretics may adversely affect these. Her
magnesium is 2.0 and her uric acid is 4.0. As previously shown, her baseline fasting
blood sugar, electrolytes, BUN, and creatinine are normal.
2. The patient should be taught to take the medication at the same time every day, in the
morning. She should be taught to change positions slowly, avoid exercising in hot
weather, and weigh herself daily. She should report weight losses of more than 1 lb per
day or more than 5 lb per week, excessive thirst, muscle pain, weakness or cramps,
nausea, vomiting, diarrhea, or increased HR. She should be discouraged from taking
NSAIDs, as these may reduce the diuretic effect and may worsen HTN. Acetaminophen
is an alternative treatment for her headaches.
3. The patient should return to have her serum electrolytes rechecked in 1 week, and
potassium supplementation should be started if serum potassium level is less than 3.5.
4. The patient now has established cardiac risk factors of positive family history, obesity,
HTN, and hyperlipidemia. As her LDL is greater than 130, a TLC diet is recommended
as first-line management of her hyperlipidemia. This diet is low in saturated fat, low in
total cholesterol, high in plant sterols, high in soluble fiber, and is calorie-appropriate to
promote weight loss, if indicated. The patients fasting lipid profile should be rechecked
after 3 months on TLC diet therapy, so that a decision may be made regarding the
addition of antilipidemic medication.
5. You decide to see the patient back in 1 month, to reassess her BP on the diuretic therapy,
because the diuretic dose should be increased at no less than a 1-month interval.

Second Follow-Up Visit

Her BP is 142/84 and HR is 76 after 1 month on the diuretic therapy. She has had no problems
with the diuretic medication. However, she complains that the acetaminophen does not
adequately treat her migraine headaches. She is pursuing a TLC diet and has started a walking
program.
Modifications of Treatment Plan
1. Because she has migraines, and her BP is still above the goal of less than or equal to
139/89, a rational choice of a second antihypertensive medication would be a beta
blocker. Because she has to pay for half of each prescription, atenolol is the cheapest of
the beta blockers. You elect to start her on atenolol 25mg daily. Although beta blockers
can transiently decrease the HDL and increase triglycerides, their use in the setting of
hyperlipidemia is not contraindicated.
2. The patient should be taught to check her BP and HR at home, and to keep a diary of
these readings to bring with her to each clinic visit. She should be taught to change
positions slowly, and to report dizziness and HR below 50 or systolic BP less than 100.
3. You decide to see the patient back in 2 months to review her BP and HR readings, and
the repeat of her fasting lipid profile.
Continuing Care
1. At 3 months after your initial visit with Ms. DA, her BP is 122/64 and HR is 68 on the
HCTZ 12.5 mg daily and atenolol 25 mg daily. Her migraine headaches have resolved.
2. Her repeat total cholesterol is 202, triglycerides are 160, LDL is 140, and HDL is 44.
Because you know that African Americans are disproportionately affected by

cardiovascular disease risks, you elect to start her on a statin medication, because her
LDL remains over 130. Lovastatin is the least expensive of the statins, and you initiate
lovastatin 20 mg PO daily with her evening meal.
3. She is taught to continue her TLC diet; to avoid large quantities of grapefruit, which may
increase myopathies; and to take this medication with food. Muscle tenderness and
weakness should be reported to the prescriber. Gastrointestinal symptoms and headaches
are usually mild and transitory.
4. You will recheck her AST, ALT, and fasting lipid profile in 4 to 6 weeks.