Guest guest Posted February 10, 2011 Report Share Posted February 10, 2011 There is good data showing reducing systolic pressure below 160 notably cut down risk of stroke and MI, stroke specifically. There is no great data showing SBP reductions to less than 140 in ISH improve outcomes. Doesn't mean it doesn't but there is no data. From what I've heard other testing is likely not necessary and wouldn't change management. One option would be to try long acting nifedipine as opposed to amlodipine which I have found you can titrate up a little higher without having as much swelling as one does on amlodipine. Since she's tolerating diuretics those are reasonable to keep on board though always be careful with hypoNA in little old ladies on diuretics. Chlorthalidone is actually a better BP medication than HCTZ though never used in the US for some reason and another option to switch in for HCTZ. Finally, I would ensure she's not going crazy with packaged or prepared foods or salt intake. If she's had HTN for a while (and you as a doctor) she's likely already doing that but something to double check. Sometimes people get hooked on something new and don't realize the sodium intake. There are some small studies looking at BP reductions in folks already on 2-3 medications and aggressive sodium reduction (<1500 mg daily) can dropped SBP 10-20 points. Some additional thoughts, ignoring her age. I know, but play along for academic purposes. I'd get an echo to r/o valve dz. Consider spironolactone and a spot renin/aldosterone level. Look into one of the new renin blockers as a possibility. OSA can cause a sympathetic overdrive leading to hypertension that's hard to control. Treating the OSA can make a big difference. Renal artery stenosis? Personally, I'm of the school that old ladies with SBP 140-150 is ok if they are symptomatic with lower BPs and may fall down go boom. SBP in the 180-200 range scares me regardless of age. I usually look for a secondary cause like OSA, renal artery stenosis, hyperaldosteronism, valvular abnormality. Then again, I'm an internist with lots of pens and we usually like to order tests. > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 10, 2011 Report Share Posted February 10, 2011 But isn;t that Data in people 10+ yrs younger than her? There is good data showing reducing systolic pressure below 160 notably cut down risk of stroke and MI, stroke specifically. There is no great data showing SBP reductions to less than 140 in ISH improve outcomes. Doesn't mean it doesn't but there is no data. From what I've heard other testing is likely not necessary and wouldn't change management. One option would be to try long acting nifedipine as opposed to amlodipine which I have found you can titrate up a little higher without having as much swelling as one does on amlodipine. Since she's tolerating diuretics those are reasonable to keep on board though always be careful with hypoNA in little old ladies on diuretics. Chlorthalidone is actually a better BP medication than HCTZ though never used in the US for some reason and another option to switch in for HCTZ. Finally, I would ensure she's not going crazy with packaged or prepared foods or salt intake. If she's had HTN for a while (and you as a doctor) she's likely already doing that but something to double check. Sometimes people get hooked on something new and don't realize the sodium intake. There are some small studies looking at BP reductions in folks already on 2-3 medications and aggressive sodium reduction (<1500 mg daily) can dropped SBP 10-20 points. Some additional thoughts, ignoring her age. I know, but play along for academic purposes. I'd get an echo to r/o valve dz. Consider spironolactone and a spot renin/aldosterone level. Look into one of the new renin blockers as a possibility. OSA can cause a sympathetic overdrive leading to hypertension that's hard to control. Treating the OSA can make a big difference. Renal artery stenosis? Personally, I'm of the school that old ladies with SBP 140-150 is ok if they are symptomatic with lower BPs and may fall down go boom. SBP in the 180-200 range scares me regardless of age. I usually look for a secondary cause like OSA, renal artery stenosis, hyperaldosteronism, valvular abnormality. Then again, I'm an internist with lots of pens and we usually like to order tests. > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 10, 2011 Report Share Posted February 10, 2011 id have to go back and look at the studies but the last lecture on this topic i went to was discussing studies that were specific to those aged 75 and up i'm pretty sure But isn;t that Data in people 10+ yrs younger than her? There is good data showing reducing systolic pressure below 160 notably cut down risk of stroke and MI, stroke specifically. There is no great data showing SBP reductions to less than 140 in ISH improve outcomes. Doesn't mean it doesn't but there is no data. From what I've heard other testing is likely not necessary and wouldn't change management. One option would be to try long acting nifedipine as opposed to amlodipine which I have found you can titrate up a little higher without having as much swelling as one does on amlodipine. Since she's tolerating diuretics those are reasonable to keep on board though always be careful with hypoNA in little old ladies on diuretics. Chlorthalidone is actually a better BP medication than HCTZ though never used in the US for some reason and another option to switch in for HCTZ. Finally, I would ensure she's not going crazy with packaged or prepared foods or salt intake. If she's had HTN for a while (and you as a doctor) she's likely already doing that but something to double check. Sometimes people get hooked on something new and don't realize the sodium intake. There are some small studies looking at BP reductions in folks already on 2-3 medications and aggressive sodium reduction (<1500 mg daily) can dropped SBP 10-20 points. Some additional thoughts, ignoring her age. I know, but play along for academic purposes. I'd get an echo to r/o valve dz. Consider spironolactone and a spot renin/aldosterone level. Look into one of the new renin blockers as a possibility. OSA can cause a sympathetic overdrive leading to hypertension that's hard to control. Treating the OSA can make a big difference. Renal artery stenosis? Personally, I'm of the school that old ladies with SBP 140-150 is ok if they are symptomatic with lower BPs and may fall down go boom. SBP in the 180-200 range scares me regardless of age. I usually look for a secondary cause like OSA, renal artery stenosis, hyperaldosteronism, valvular abnormality. Then again, I'm an internist with lots of pens and we usually like to order tests. > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 16, 2011 Report Share Posted February 16, 2011 I agree. I would check her valves with an echo first. Do you hear any murmur? AR can cause wide pulse pressures with an end diastolic murmur.Sent from my iPhoneNita With a wide pulse pressure like that, I would want to make sure aortic stenosis wasn't playing a role in her worsening hypertension. If so, lowering her bp with multiple meds could cause syncope and possibly worse. Ben Quote Link to comment Share on other sites More sharing options...
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