Mr FH, a 50-year-old van driver, was identified by his general practitioner (GP) as having a resting blood pressure of 162/92 mmHg. He was in reasonably good health and purchased over-the-counter (OTC) ibuprofen 400 mg, which he took up to three times daily for arthritis-type pain when necessary. He weighed 95 kg, was 5’7” tall, and had a resting pulse rate of 82 beats per minute (bpm). He smoked 15 cigarettes per day and drank at least 6 units on 4 nights each week. His total cholesterol (TC) had been measured as 5.9mmol/L and his high-density lipoprotein (HDL) as 1.5 mmol/L (TC:HDL ratio 4.5).
Mr FH continued to visit his medical centre at 2-monthly intervals, but his blood pressure remained raised, despite the prescribed ramipril. Nine months later, Mr FH was admitted to the the local hospital, having collapsed at work with chest pains, which resolved rapidly after sublingual glyceryl trinitrate. He admitted that he had been getting chest pains on exertion for ‘a couple of months’. His blood pressure was measured as 165/99 mmHg.
His haematology and biochemistry results are as follows:
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a. Sodium 140 mmol/L (135–145)
b. Potassium 4.9 mmol/L (3.5–5)
c. Blood glucose 4.1 mmol/L
d. Creatinine 130 micro mol/L (<110)
a.Glycated haemoglobin (HbA1c) 6.7%
b.Haemoglobin 11.2 g/dL (12–18)
c.TC 7.1 mmol/L
His current therapy was:
a.Ramipril 5 mg daily
b.Simvastatin 10 mg daily
c.Aspirin 75 mg daily
d.Paracetamol 1 g four times daily when required
He admitted to continuing to buy OTC ibuprofen and not being terribly compliant with his statin therapy.
Questions for case evaluation;
1. Why is it important to control blood pressure?
2. How would you assess Mr FH’s cardiovascular disease (CVD) risk?
3. What non-drug approaches can Mr FH adopt to reduce his blood pressure and/or his cardiovascular (CV) risks, and why are these important?
4. What first-line treatments would be suitable for Mr FH’s hypertension?
5. Suggest a suitable initial dose, titration regimen, and any monitoring required. What counselling would Mr FH require?
6. What target blood pressure is appropriate for Mr FH?
7. How frequently would you monitor Mr FH’s progress, in terms of blood pressure values, biochemical tests and possible side-effects?
8. Should Mr FH be started on aspirin and a statin?
9. Mr FH wishes to monitor his own blood pressure at home. What would be your recommendation? 10. What special considerations apply to the management of hypertension in the elderly?