Response – Management of Hypertensive Crisis in a High-Risk Elderly Patient

Response – Management of Hypertensive Crisis in a High-Risk Elderly Patient

Responding to Alison

Hello,

Your post discusses a very important case of a 64-year-old black man with uncontrolled hypertensive disease, which is especially a big issue given his current blood pressure ranging from 195/115 mm/Hg and symptoms that include headache and blurring of vision. The actions you suggested to manage the condition, such as medication, dosage, and other lifestyle changes, are appropriate in recent clinical guidelines. The decision to start a moderate-potency statin like atorvastatin is anchored on the ASCVD risk estimator, which gives an estimate of a 36.7 percent chance of a cardiovascular event within the subsequent ten years. This is in line with the AHA guidelines, which avail statin therapy to those with a high risk of ASCVD (Anderson et al., 2024). Additionally, you suggested an increment in the dose of hydrochlorothiazide, and based on the recommendation of the JNC 8 guidelines, raising the dose of thiazide diuretic is effective in hypertensive patients, more so the African American population (Shani et al., 2019).

Your plan to educate the patient on the changes to dietary management, such as following the DASH dietary plan, is essential. The findings suggest that diet change may help reduce blood pressure and decrease the hazard of cardiovascular disease (Uliatiningsih & Fayasari, 2019). In the same respect, attention should also be paid to the frequency of drinking fluids and practicing physical exercise that may complement the pharmacological treatment. Follow-up care is also crucial since the change in antihypertensive therapy, particularly the use of diuretics, requires assessment of renal function and potassium level. It is prudent to refer the patient to a nutritionist, and a cardiologist is an aggressive approach that caters to the patient’s cardiovascular risk in an elaborate manner.

Altogether, your clinical reasoning and the management plan proposed are consistent with the best available evidence synthesized optimally and unambiguously, indicating an understanding of the previously outlined considerations pertinent to antihypertensive therapy in high-risk patients. Education and follow-up are also the areas that will ensure sustained and best results are achieved.

References

Anderson, T. S., Wilson, L. M., & Sussman, J. B. (2024). Atherosclerotic Cardiovascular Disease Risk Estimates Using the Predicting Risk of Cardiovascular Disease Events Equations. JAMA Internal Medicine, e241302. https://doi.org/10.1001/jamainternmed.2024.1302

Shani, M., Lustman, A., & Vinker, S. (2019). Adherence to oral antihypertensive medications, are all medications equal? The Journal of Clinical Hypertension, 21(2), 243–248. https://doi.org/10.1111/jch.13475

Uliatiningsih, R., & Fayasari, A. (2019). Effect Education of DASH DIET on Dietary Intake Adherence and Blood Pressure of Hypertension Outpatients in Rumkital Marinir Cilandak. Jurnal Gizi Dan Pangan Soedirman, 3(2), 120. https://doi.org/10.20884/1.jgps.2019.3.2.1924

Responding to Hamid

Hello,

The clinical case that you described presents a patient with a hypertensive crisis where a patient has severe hypertension, including acute signs like headaches and blurred vision. You were right to point out that the initial goal is to determine whether the patient has a hypertensive emergency, which is characterized by severe hypertension of 180/120 mm Hg and signs of acute target organ dysfunction (Unger et al., 2020). Your differential diagnoses are quite rational and reasonable, especially the choice of hypertensive emergency as the most imminent danger. Since pain, headaches, and vision alterations can indicate end-organ dysfunction, with neurological systems being especially sensitive in this case, patient symptoms include headaches and bad vision. Although stroke is a differential diagnosis, the patient’s age and risk factors make a diagnosis of hypertensive emergency because of the acute onset.

From the management aspect, the first action in your care plan, referring the patient to the emergency department, is imperative. For brain imaging, CT or MRI is recommended with the cardiac evaluation EKG to ensure there is no acute ischemic event or any complications regarding cardiac issues (Elliott et al., 2023). Extremely low BP requires delicate management because sharp changes may cause cerebral ischemia, renal failure or bloody diarrhea. The ideal should be to bring down the BP progressively and, in the process, closely observe the affected individual. Your current strategy with respect to the long-term management of this case, including the frequency of clinic visits, how to reduce the dosage of medications, and the approach to managing lipid levels, is correct. Lifestyle changes are equally critical; recommendations for dietary and exercise changes and smoking cessation decrease the risk of cardiovascular diseases (Whelton et al., 2018). Such check-ups will assist in monitoring the patient’s compliance with the medication to make necessary changes in dose or type of medication as and when necessary. In any case, the interpretation of the case is comprehensive; thus, the management plan suitable corresponds to the General Clinical Management for Hypertensive Emergencies. Probably the most important elements are constant supervision and teaching of the clients how to identify signs of developing complications.

References

Elliott, J. E., Lim, M. M., Keil, A. T., Postuma, R. B., Pelletier, A., Gagnon, J. F., … & Schenck, C. (2023). Baseline characteristics of the North American prodromal Synucleinopathy cohort. Annals of Clinical and Translational Neurology, 10(4), 520-535.

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., … & Schutte, A. E. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334-1357.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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. Journal of the American College of Cardiology, 71(19), e127-e248.

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PEER RESPONSE 1:

Alison Anderson

In this week’s discussion post, we are going to discuss a patient that is a sixty-four year-old black male that has presented to the clinical with complaints of headaches and blurry vision for two days. The patient has a known history of hypertension. He is currently on Hydrochlorothiazide 12.5mg and Metoprolol 50mg BID. He last took his medication this morning, however his blood pressure was 195/115. Based upon this reading and his recent lab work, this patient needs a change in medication regimen. The differential diagnosis for this patient include primary hypertension and mixed hyperlipidemia. The goals for this patient, is to ultimately decrease his risk for a cardiovascular event such as a stroke or myocardial infarction within the next ten years.

Management of Hypertensive Crisis in a High-Risk Elderly Patient

Treatment

When utilizing the ASCVD risk calculator, this patient has a 36.7% risk of having a MI or stroke in the next ten years. According to the guideline, a statin should be started at moderate intensity (Wilson, 2024). This patient also could have an increase in his blood pressure medication. Considering he is an African American, thiazide or thiazide like diuretics are the medication of choice according to the JNC guidelines (Egan, 2023). This patient is on a low dose of hydrochlorothiazide. I would choose to increase the dose of hydrochlorothiazide. His heart rate was also on the higher end of normal, therefore it would also be safe to increase his dose of Metoprolol to assist his blood pressure. I would prescribe the following medications:

• Atorvastatin 10mg QD #30 with 3 refills
• Hydrochlorothiazide 25mg QD #30 with 3 refills
• Metoprolol 100mg BID #60 with 3 refills

Education

This patient would benefit from education regarding diet, exercise, and increasing water intake. Following a diet specifically like DASH diet would help decrease sodium intake and help lower cholesterol levels (Clarke, 2023).

Follow Up

I would check this patient’s renal function due to the increase in medications, along with a potassium level in roughly three months. I would also consider a referral to a nutritionist for education on low cholesterol and heart healthy diet. I would also refer this patient to a cardiology considering he is at a moderate risk for heart disease.

PEER RESPONSE 2:

Hamid Ahmad

From what we know, this patient is in a cardiac crisis. In addition to having high blood pressure, this person has a headache and blurry vision. His history of high blood pressure and his recent symptoms point to several possible diagnoses. However, the patient’s serious hypertension and immediate effects on his organs (headaches and vision problems) make it most likely that he is experiencing an emergency hypertensive episode. A hypertensive emergency is when a person has a very high blood pressure and organ damage is caused by the high blood pressure. The retina, brain, heart, large arteries, and kidneys are some of the organs that are being targeted. When BP is >170 mm Hg systolic and/or >110 mm Hg diastolic, the person needs to be taken to the hospital right away (Unger et al., 2020).

Differential Diagnosis

• Hypertensive emergency: It is described as high blood pressure with signs of recent heart damage. This might show up as problems with the nervous system (headaches, confusion), the kidneys, or the heart. In this case, the headaches and blurred vision suggest that an acute target organ may be involved, such as the retina or the brain (Vemu et al., 2024).
• Stroke (Transient Ischemic Attack or Ischemic Stroke): Because of his age, vascular risk factors, and sudden onset of neurological complaints, it is not likely that he had a cerebrovascular event (Unger et al., 2020).
• Secondary Hypertension: Secondary reasons of hypertension should be considered, even though the patient is on antihypertensive drugs, especially since he is so hard to control. These could be renal artery stenosis, pheochromocytoma, or primary aldosteronism.
• Migraine: Headaches and vision problems are some of the symptoms of migraines that this patient may be having. However, because of the patient’s age and severe high blood pressure, it is very important to rule out more serious problems first, like a hypertensive emergency. As an alternative, migraine could be considered if those don’t work, especially if the patient has had similar attacks in the past.

Main Diagnosis: Hypertensive emergency

ASCVD risk Assessment: The patient has a 36.7% ASCVD risk over the next 10 years. This puts him in a very high-risk group for stroke and heart attack. Because of this high risk, aggressive treatment plans are needed to lower the chance of future cardiovascular events.

Plan

• Immediate Plan
  • When creating a treatment plan for a patient experiencing a hypertensive emergency, it is crucial to avoid lowering blood pressure too rapidly, as this can lead to negative outcomes. Additionally, the patient’s high cholesterol levels increase the risk of a cerebrovascular accident (CVA) or stroke. Therefore, an urgent referral to the emergency department is necessary for acute blood pressure management and further evaluation to exclude any acute end-organ damage. In the emergency department, the patient should receive appropriate assessments, including brain imaging (such as a CT or MRI) to rule out a stroke, EKG to detect any signs of cardiac ischemia, CXR or CT of chest to assess for cardiomegaly, CBC for evaluation of overall health, and a fundoscopic exam to check for retinal damage. This thorough evaluation is essential to address the immediate risks and potential complications associated with the hypertensive emergency (Elliott et al., 2023).
• Long-term plan
  • A comprehensive approach to managing the patient’s hypertensive emergencies and cardiovascular risks is needed for long-term care. The drug regimen may need to be adjusted to optimize hydrochlorothiazide and metoprolol dosages and include a calcium channel blocker like amlodipine or an ACE inhibitor like lisinopril for blood pressure control. Given the patient’s high LDL and total cholesterol, atorvastatin or rosuvastatin should be started to regulate his lipid levels, with a 3-6-month lipid panel to check treatment efficacy and adherence (Whelton et al., 2018).
  • In addition, making lifestyle changes will be very important for his long-term care. Diet changes to lower fat and sodium intake, regular physical exercise as tolerated, and, if possible, quitting smoking should all be strongly urged. According to the most recent guidelines, the patient has a 36.7% chance of ASCVD, so lowering their blood pressure and LDL cholesterol levels is very important (Whelton et al., 2018).
  • Follow-up visits should be set up regularly, first one week after leaving the emergency room and then once a month to closely watch blood pressure and look for any side effects of medications. If you change any of your medications, you should get another check-up in 4 to 6 weeks to make sure they are still working well and are safe for you (Whelton et al., 2018).
  • Referrals to a cardiologist for specialized ASCVD risk management and to an ophthalmologist for a thorough eye examination are recommended due to the patient’s symptoms of blurry vision. A consultation with a dietitian could provide valuable guidance on dietary changes. Furthermore, it is vital to educate the patient on recognizing the signs and symptoms of potential complications like stroke and the importance of strict adherence to his medication regimen to mitigate the risk of adverse outcomes (Whelton et al., 2018).