A-Textbook-of-Clinical-Pharmacology-and-Therapeutics-5th-edition

OTHER ANTIHYPERTENSIVE DRUGS 195
Case history
A 72-year-old woman sees her general practitioner because
of an Escherichia coli urinary infection. Her blood pressure is
196/86 mmHg. She had had a small stroke two years previously,
which was managed at home, and from which she
made a complete recovery. At that time, her blood pressure
was recorded as 160/80 mmHg. She looks after her husband
(who has mild dementia) and enjoys life, particularly visits
from her grandchildren. She smokes ten cigarettes/day, does
not drink any alcohol and takes no drugs. The remainder of
the examination is unremarkable. Serum creatinine is normal,
total cholesterol is 5.6 mmol/L and HDL is 1.2 mmol/L.
The urinary tract infection resolves with a short course of
amoxicillin. This patient’s blood pressure on two further
occasions is 176/84 and 186/82 mmHg, respectively. An ECG is
normal. She is resistant to advice to stop smoking (on the
grounds that she has been doing it for 55 years and any
harm has been done already) and the suggestion of drug
treatment (on the grounds that she feels fine and is ‘too old
for that sort of thing’).
Questions
Decide whether each of the following statements is true or
false.
(a) This patient’s systolic hypertension is a reflection of a
‘stiff’ circulation, and drug treatment will not improve
her prognosis.
(b) Drug treatment of the hypertension should not be contemplated
unless she stops smoking first.
(c) If she agrees to take drugs such as thiazides for her
hypertension, she will be at greater risk of adverse
effects than a younger woman.
(d) Attempts to discourage her from smoking are futile.
(e) An α 1 -blocker would be a sensible first choice of drug,
as it will improve her serum lipid levels.
(f) Aspirin treatment should be considered.
Answer
FURTHER READING
Dahlof B, Sever PS, Poulter NR et al. Prevention of cardiovascular
events with an antihypertensive regimen of amlodipine adding
perindopril as required versus atenolol adding bendroflumethiazide
as required, in the Anglo-Scandinavian Cardiac Outcomes
Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre
randomised controlled trial. Lancet 2005; 366: 895–906.
Furberg CD, Wright JT, Davis BR et al. Major cardiovascular events in
hypertensive patients randomized to doxazosin vs chlorthalidone –
The Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT). Journal of the American Medical
Association 2000; 283: 1967–75.
Furberg CD, Wright JT, Davis BR et al. Major outcomes in high-risk
hypertensive patients randomized to angiotensin-converting
enzyme inhibitor or calcium channel blocker vs diuretic – The
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart
Attack Trial (ALLHAT). Journal of the American Medical Association
2002; 288: 2981–97.
Goodfriend TL, Elliott ME, Catt KJ. Angiotensin receptors and their
antagonists. New England Journal of Medicine 1996; 334: 1649–54.
Palmer BF. Current concepts: Renal dysfunction complicating the
treatment of hypertension. New England Journal of Medicine
2002; 347: 1256–61.
Setaro JF, Black HR. Refractory hypertension. New England Journal of
Medicine 1992; 327: 543–7.
Sibai BM. Treatment of hypertension in pregnant women. New
England Journal of Medicine 1996; 335: 257–65.
Staessen JA, Li Y, Richart T. Oral renin inhibitors. Lancet 2006; 368:
1449–56.
Swales JD (ed.). Textbook of hypertension. Oxford: Blackwell Science,
1994.
van Zwieten PA. Central imidazoline (I1) receptors as targets of centrally
acting antihypertensives: moxonidine and rilmenidine.
Journal of Hypertension 1997; 15: 117–25.
(a) False
(b) False
(c) True
(d) False
(e) False
(f) True.
Comment
Treating elderly patients with systolic hypertension reduces
their excess risk of stroke and myocardial infarction. The
absolute benefit of treatment is greatest in elderly people
(in whom events are common). Treatment is particularly
desirable as this patient made a good recovery from a stroke.
She was strongly discouraged from smoking (by explaining
that this would almost immediately reduce the risk of a further
vascular event), but she was unable to stop. Continued
smoking puts her at increased risk of stroke and she agreed
to take bendroflumethiazide 2.5 mg daily with the goal of
staying healthy so that she could continue to look after her
husband and enjoy life. She tolerated this well and her blood
pressure fell to around 165/80 mmHg. The addition of a
long-acting ACE inhibitor (trandolapril, 0.5 mg in the morning)
led to a further reduction in blood pressure to around
150/80 mmHg. α 1 -Antagonists can cause postural hypotension,
which is particularly undesirable in the elderly.