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Chapter 42: Hypertension in High-Risk Populations

A 62-year-old obese African–American woman with hypertension and heart failure, on thiazide diuretic therapy and angiotensin-converting enzyme inhibitor (ACEI) presents for follow-up. CR 1.9 mg/dL, eGFR = 32 mL/min, echo-normal systolic function. Her blood pressure is noted to be elevated at 162/96 mm Hg.

What should the treatment plan be at this point?

A. Add a calcium channel blocker (CCB)

B. Change thiazide diuretic to a loop diuretic

C. Initiate dual therapy with an ACEI and angiotensin receptor blocker

D. Add BiDil therapy (isosorbide dinitrate and hydralazine hydrochloride)

The answer is B. African–Americans have a high risk of progression from chronic kidney disease (CKD) to end-stage renal disease (ESRD) and should be closely observed for such progression. The lower GFR (32 mL/min) is at the level where thiazide diuretics loss their efficacy. Adding a calcium channel blocker would lower blood pressure and may be necessary if changing thiazide diuretic to a loop diuretic does not work. Dual therapy with an ACEI and angiotensin receptor blocker has not been shown to be effective in patients with chronic kidney disease and may be harmful. BiDil or isosorbide dinitrate and hydralazine hydrochloride has been shown to be effective in improving outcomes in African–Americans with heart failure. While this patient has a history of heart failure her echo is presently normal. Bidil is worth considering but at this time the primary issue is blood pressure control which most likely necessitates changing thiazide diuretic to a loop diuretic.

A 61-year-old black Puerto Rican woman, with long history of type 2 diabetes, hypertension, coronary artery disease, and hyperlipidemia presents to your office. She speaks limited English and has recently moved from Puerto Rico to join family. Current medications: Metformin, Glipizide, Losartan, Hydrochlorothiazide (HCTZ), Aspirin (ASA), Atorvastatin. Office blood pressure is 156/94. It is not clear if she is following her recommended DASH diet and prescribed medications.

Which of the following is least likely to help address potential adherence concerns?

A. Have her tell you about what she eats, how she prepares it and why

B. Provide her with a quality hypertension brochure

C. Inquire if her insurance covers her medications

D. Inquire about her medication copayment

The answer is B. Inquiry to discern dietary habits can be helpful especially to assess sodium intake. An understanding of her insurance coverage and related issues such as medication copayment if she does have insurance can help to better assess her ability ...

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