1. Ischemic stroke, hemorrhagic stroke, hypertension, hypertensive crisis
Therapeutics I
Ischemic stroke, hemorrhagic stroke, hypertension, hypertensive crisis

2. Tips for Success
Carefully consider which guidelines you are basing your treatment decisions on.
Read the question, then go back and read through the case to save time.
Consider the guidelines, but also consider the patient! Is their K high? Don’t put them on a ACEI/ARB. Do they have BPH? Consider addition of an alpha blocker. Does the patient already experience lower-limb edema? You might not put them on a DHP CCB.
For stroke and HTN crisis, know which meds are IV bolus and which are CIVI.

3. TE is a 67 yo WM presenting to the hospital with recent onset of difficulty speaking and immobility of his left leg and foot. His daughter notes that he has a PMH of high blood pressure and cholesterol, and his BP upon presentation is 210/100. He is s/p carotid stent placement 3 months ago. After being admitted, TE lost consciousness.
The treatment team decides to to perform an examination using the National Institute of Health Stroke Severity Scale (NIHSS). Which of the following is not a benefit of the NIHSS?
Rapid assessment of neurologic deficits and potential complications
Excellent repeatability
Administered by physicians in acute setting
Facilitates communication with a common language
C- can be administered by a wide variety of health care professionals, not just physicians! If provides rapid assessment of stroke severity, neurologic deficits, estimation of vessel occlusion location, early prognosis, potential complications. it provides a common language across health care disciplines for better communication
What are the symptoms of ischemic stroke in this patient? Difficulty speaking, immobility of left leg/foot (FAST acronym, face drooping, arm weakness, speech difficulty, time to call 911)
What are his risk factors? High blood pressure, high cholesterol, s/p carotid stent (increased chance of a clot forming and breaking off)

4. TE is a 67 yo WM presenting to the hospital with recent onset of difficulty speaking and immobility of his left leg and foot. His daughter notes that he has a PMH of high blood pressure and cholesterol, and his BP upon presentation is 210/100. He is s/p carotid stent placement 3 months ago. After being admitted, TE lost consciousness.
Which NIHSS score might you expect to have the best prognosis? 4 6 15 20 4
1-4 is minor stroke, patients with this score could potentially still be independent upon leaving the hospital
5-15 is moderate stroke
16-20 is moderately severe
>20 is severe stroke. These patients will have to be cared for, and have a high mortality as well

5. TE is a 67 yo WM presenting to the hospital with recent onset of difficulty speaking and immobility of his left leg and foot. His daughter notes that he has a PMH of high blood pressure and cholesterol, and his BP upon presentation is 210/100. He is s/p carotid stent placement 3 months ago. After being admitted, TE lost consciousness.
Which cerebral artery is most likely occluded in TE?
PCA
ACA
MCA
B- anterior cerebral artery.
ACA occlusion mostly leads to some paralysis and effects in the lower limbs, while MCA occlusion leads to paralysis effects in the face and arms.
PCA occlusion leads to things like loss of pain and temperature sensation, visual problems, other.
What could be a potential etiology? Atherosclerosis, emboli from heart (recent surgery), cryptogenic (or unknown etiology)
Do we want to treat this patient’s blood pressure? Not unless we want to administer t-PA. if TE is not a candidate, then we don’t want to lower the pressure unless it is >220/120 of it aortic dissection, acute myocardial dysfunction, pul edema, hypertensive encephalopathy

6. NP is a 49 yo AAF presenting to the ED with symptoms of ischemic stroke beginning 90 minutes ago. His NIHSS score was documented as 16, and his BP reading is 185/100. He takes warfarin for his atrial fibrillation, but has been non-compliant based on his INR of 1.5. NP weighs 120 kg and his BMI is 35.
Can the healthcare team administer alteplase at this time?
Yes No
B- his BP is too high! Must be <185/110 for initiation of therapy. Must maintain BP <185/105 during administration of t-PA.
Is he within the time frame of symptom onset? Yes, presented within hrs of symptom onset
Is his NIHSS score an issue? No, relative exclusion is severe stroke NIHSS>25
Is his INR an issue? No, <1.7
Is his warfarin therapy an issue? Relative exclusion is any oral anticoagulation regardless of INR
What if he didn’t have Afib, so he wasn’t on anticoagulation. If his BP continued to rise and he was not a candidate for t-PA, what could we give him ASAP instead??

7. NP is a 49 yo AAF presenting to the ED with symptoms of ischemic stroke beginning 90 minutes ago. His NIHSS score was documented as 16, and his BP reading is 185/100. He takes warfarin for his atrial fibrillation, but has been non-compliant based on his INR of 1.5. NP weighs 120 kg and his BMI is 35.
The healthcare team administers nicardipine to lower NP’s blood pressure. His blood pressure falls to 180/95 in the next 30 minutes (120 min since onset of symptoms), so the health care team decides to administer t-PA. What dose should the team administer?
110 mg over 60 minutes, 11 mg given as bolus over 1 minute
110 mg over 60 minutes, 22 mg given as bolus over 1 minute
90 mg over 60 minutes, 9 mg given as bolus over 1 minute
120 mg over 60 minutes, 12 mg given as bolus over 1 minute
C- 0.9 mg/kg or a MAX dose of 90 mg! admin over 60 min. 10% of the total dose is given as a bolus over 1 minute (9 mg here)

8. NP is a 49 yo AAF presenting to the ED with symptoms of ischemic stroke beginning 90 minutes ago. His NIHSS score was documented as 16, and his BP reading is 185/100. He takes warfarin for his atrial fibrillation, but has been non-compliant based on his INR of 1.5. NP weighs 120 kg and his BMI is 35.
What is the most appropriate medication regimen on which to discharge this patient?
ASA 325 mg, VKA 10 mg, atorvastatin 20 mg, amlodipine 10 mg
Apixaban 5 mg BID, rosuvastatin 20 mg, HCTZ 25 mg
ASA 81 mg, atorvastatin 80 mg, VKA 5 mg, clopidogrel 75 mg
Rivaroxaban 20 mg, ASA 81 mg, clopidogrel 75 mg C.
ASA therapy: indicated 24 hr after t-PA, ASAP as monotherapy if the patient is not a t-PA candidate and is not a candidate for anticoagulation (no Afib)
clopidogrel is an alternative, so is dipyridamole (except not tolerated well)
Statin therapy: high intensity in all patients who have experienced an ischemic stroke. Atorvastatin 40-80, rosuvastatin 20-40
Anticoagulation: VKA, apixaban, dabigatran therapy are all indicated in this patient. Rivaroxaban is also reasonable (lower level recommendation).

9. GS has received t-PA 8 hrs ago for ischemic stroke
GS has received t-PA 8 hrs ago for ischemic stroke. He suddenly began to demonstrate neurological deterioration (GCS 6) and recently lost consciousness. The health care team suspects an intracerebral hemorrhage. His blood pressure is 160/95.
What is the most appropriate course of action for this patient?
Administer aminocaproic acid and monitor intracranial pressure.
Administer nicardipine to lower blood pressure and FFP
Administer FEIBA and amlodipine to lower blood pressure
Administer aminocaproic acid for fibrinolytic reversal and nicardipine CIVI
D- aminocaproic acid is the reversal agent for t-PA. also our options to lower BP at this time are labetalol and hydralazine IV bolus, and the nicardipine and clevidipine are continuous infusion (easily titratable). FEIBA is for our NOACs, and FFP would be for warfarin. Amlodipine would be too slow acting.
What is our blood pressure goal? SBP <140
We actually want to lower the blood pressure in these patients, because they are bleeding out. As opposed to ischemic stroke, where the patient’s perfusion is compromised.
What if our patient’s blood pressure was >220? SBP <140, aggressive reduction bc have to lower it so much

10. Which of the following is not a potential reversal agent for warfarin?
FFP
PCC
Phytonadione
Activated charcoal
D- charcoal can be used for the NOACs
FFP is fresh frozen plasma, which can be used to replace all cofactors including vitamin-K dependent factors (II, VII, IX, X which are the factors that VKA depletes)
PCC is prothrombin complex concentrates, contains different combinations of vit K dependent factors II, VII, IX, X and Protein C and Protein S

11. TS is a 45 yo patient with atrial fibrillation
TS is a 45 yo patient with atrial fibrillation. She was initiated on 150 mg of dabigatran BID two weeks ago after discontinuing a warfarin regimen due to the dietary restrictions. TS’s sister brought her to the ED after experiencing excessive N/V, and loss of consciousness. She was diagnosed with ICH after imaging.
What is the best course of action for this patient?
Administer Praxbind
Administer activated charcoal
Administer IV fluids and monitor intracranial pressure
Begin hemodialysis immediately A
NOAC reversal agents: FEIBA (activated PCC), PCC (Kcentra), rFVIIa, activated charcoal
Dabigatran can be dialyzed (typically only use HD to remove if the patient already has a port/catheter in place for dialysis)
Which two reversal agents can be used for ALL anticoagulants? (VKA, dabigatran, rivaroxaban, apixaban) FEIBA and Kcentra

12. JT is a 35 yo AAM with a history of mitral valve replacement (mechanical) who has recently been admitted for suspicion of ICH. CT scan has confirmed bleeding into internal ventricle on the left side of the brain. He is currently on a regimen of ASA 81 mg Qday and VKA 5 mg MWF, 2.5 mg TThS. He has a PMH of mitral valve disease and denies tobacco use, although claims that he drinks about 8 beers while cheering on the Vols on Saturdays.
What is the best course of action for this patient?
Administer IV vitamin K and continuous infusion hydralazine to SBP < 140
Administer Kcentra and IV bolus nicardipine to SBP <160
Discontinue warfarin and administer continuous infusion nicardipine to SBP <160
Administer IV vitamin K and continuous infusion nicardipine to SBP <140 D
The SBP goal for ICH is <140, not 160. also we need to discontinue the warfarin and the ASA acutely, and administer a reversal agent for the warfarin.
IV vitamin K and Kcentra are both options! And FFP or FEIBA could be options.

13. JT is a 35 yo AAM with a history of mitral valve replacement (mechanical) who has recently been admitted for suspicion of ICH. CT scan has confirmed bleeding into internal ventricle on the left side of the brain. He is currently on a regimen of ASA 81 mg Qday and VKA 5 mg MWF, 2.5 mg TThS. He has a PMH of mitral valve disease and denies tobacco use, although claims that he drinks about 8 beers while cheering on the Vols on Saturdays.
What risk factors does this patient posses for ICH recurrence?
Mechanical mitral valve: will need lifelong anticoagulation… have to weigh the risk vs. benefit
Excessive drinking is a risk factor too, so should limit that in the future
Other risk factors to watch for: older patients, presence of microbleeds on MRI, presence of apolipoprotein alleles

14. A patient presents to the ED with sudden onset of extremely painful headache. A CT scan is performed, and the patient is diagnosed with a subarachnoid hemorrhage secondary to a cerebral aneurysm. The patient’s blood pressure is 180/105.
What is the best initial course of action for this patient?
Treat with IV esmolol to SBP <160
Clip off the aneurysm and ensure stability
Administer t-PA since blood pressure is <185/110
Treat with IV nicardipine to SBP <140
B. Secure the aneurysm (clipping/coiling)!! Also lower the BP to <160 with same agents as ischemic (IV bolus hydralazine, labetalol or CIVI nicardipine, clevidipine)

15. A patient presents to the ED with sudden onset of extremely painful headache. A CT scan is performed, and the patient is diagnosed with a subarachnoid hemorrhage secondary to a cerebral aneurysm. The patient’s blood pressure is 180/105.
This patient is at an increased risk of delayed cerebral ischemia within the first 2 weeks after the SAH. Which medication can we give the patient to reduce this risk, and for what duration?
Clevidipine 4-6 mg/hr, 14 d
Nicardipine 15 mg/hr, 21 d
Nimodipine 60 mg q4h, 21 d
Hydralazine 20 mg q4h, 14 d C
Nimodipine is CCB used to prevent vasospasm, the most likely reason for DCI. 60 mg q4h for 21 d
If hypotensive, use 30 mg q2hr

16. A patient presents to your pharmacy complaining of a throbbing headache over the past three days. The patient came in to see you because they have started experiencing some blurred vision today. You take the patient’s blood pressure and note that it is 200/125.
Is this patient experiencing a hypertensive emergency or hypertensive urgency?
Emergency
Urgency
A. definitely emergency!!
This patient’s BP is >180/120 and also has some ongoing TOD (HA, visual issues). They require IMMEDIATE BP lowering= send them to the ED!
What are some of the organ systems that we are worried about?
CNS (TIA, stroke, hypertensive encephalopathy), eyes (retinal hemorrhage, papilledema), lungs (pulmonary edema), heart (HF, aortic dissection, ACS) kidneys (acute renal failure, hematuria)

17. A patient presents to your pharmacy complaining of a throbbing headache over the past three days. The patient came in to see you because they have started experiencing some blurred vision today. You take the patient’s blood pressure and note that it is 200/125.
You send this patient to the closest Emergency Department for immediate treatment. What is this patient’s BP goal upon initiation of treatment? (current MAP is 150)
Lower BP to MAP of 113 within the next 2-6 hrs
Lower BP to goal of 160/110 within the next 1 hr
Lower BP to MAP of 38 within the next 1 hr
Lower BP to MAP of 120 within the next 1 hr
D- lower MAP by NO MORE than 20-25% within minutes to 1 hr. if fail to achieve BP decrease of at least 10 mmHg within 1 hr, rethink your strategy
Lower to goal BP of 160/ within the next 2-6 hrs
We are trying to prevent organ ischemia, when they are already under stress. What are the exceptions? Ischemic stroke (don’t treat unless >220), aortic dissection (<120 bc patient could bleed out if you don’t get the pressure down), and thrombotic use (t-PA, requires BP <185/110 for administration)

18. A patient presents to your pharmacy complaining of a throbbing headache over the past three days. The patient came in to see you because they have started experiencing some blurred vision today. You take the patient’s blood pressure and note that it is 200/125.
The ED notes that this patient has increased cranial pressure upon presentation. The patient is also noted to have some renal insufficiency (CrCl <50), glaucoma, and a soy allergy. Which of the following agents would be best to initiate in this patient to lower BP?
Fenoldopam
Clevidipine
Nicardipine
Sodium nitroprusside C.
Fenoldopam is CI with glaucoma, because increases intraocular pressure (our patient is also having vision issues, so don’t want to exacerbate)
Clevidipine is CI with egg or soy allergy! IV fat emulsion, something important to consider with tolerability
Sodium nitroprusside is not the best option with renal insufficiency (azotemia, CKD) due to formation of thiocynates that are eliminated in the urine. Also requires intra-arterial line for BP monitoring.
Nicardipine is the best choice, esp if we are suspecting some kind of stroke in our patient! Also used specifically for HTN w increased ICP

19. Which drugs are IV bolus or CIVI
Clevidipine:
Nicardipine:
Hydralazine:
Labetalol:
Esmolol:
Fenoldopam:
Sodium nitroprusside:
Nitroglycerin:
Enalaprilat:
Clevidipine: CIVI
Nicardipine: CIVI
Hydralazine: IV bolus
Labetalol: both IV bolus AND CIVI
Esmolol: CIVI
Fenoldapam: CIVI
Sodium nitroprusside: CIVI
Nitroglycerin: CIVI
Enalaprilat: IV bolus

20. DOC! Hypertensive renal disease: Coronary ischemia:
Metabolism not affected by renal/hepatic fxn:
Stroke/aortic dissection:
Excess catecholemines, pheochromocytoma or clonidone withdrawal:
Eclampsia:
Hypertensive renal disease: fenoldopam
Coronary ischemia: IV NTG
Metabolism not affected by renal/hepatic fxn: clevidipine
Stroke/aortic dissection: labetalol (2nd line for hypertensive encephalopathy)
Excess catecholemines, pheochromocytoma or clonidone withdrawal: labetalol
Eclampsia: hydralazine (no effect on fetal circulation)

21. RT is a 48 yo WM diagnosed with HTN 1 year ago, and prescribed lisinopril 10 mg Qday. He has been feeling fine over the past two months, and therefore hasn’t been taking his medication. He presents to his PCP’s office today for a check up, and his blood pressure is found to be 202/135.
What is the best course of action for RT at this time?
Send him to the ED for IV anti-HTN therapy, lower his MAP by 20-25% within the first hour
Administer clonidine 0.2 mg PO in the doctor’s office to lower his BP to 160/110 within the first hour
Re-initiate the patient’s lisinopril 10 mg Qday and follow up for re-evaluation in 3 days
Administer one dose hydralazine IV bolus in the doctor’s office now, and give second dose 60 minutes later
Administer SL IR nifedipine in the doctor’s office and observe
C- this patient is experiencing a HTN urgency, which has a different set of treatment goals
We are not as worried about TOD, so we can be a little less aggressive. The BP goal is 160/110, but we do not have to reach this within one hour. This is a goal to reach over several hours to days. You can admin dose of oral meds in the doctor’s office, and evaluate for at least 1 hr before administering a second dose.

22. AR is a 38 yo AAF presenting to the clinic today for a regular check-up. She has a PMH of T2DM and HLD. Her BP reading today is 153/90, and you note that her BP was 145/89 at her previous visit. The physician diagnoses AR with hypertension.
What is AR’s BP treatment goal based on JNC8?
<140/90
<150/90
<135/85
<130/80
A. Everyone’s goal in JNC8 is <140/90 except those patients >60 yo

23. AR is a 38 yo AAF presenting to the clinic today for a regular check-up. She has a PMH of T2DM and HLD. Her BP reading today is 153/90, and you note that her BP was 145/89 at her previous visit. The physician diagnoses AR with hypertension.
What is AR’s BP treatment goal based on ISHIB?
<140/90
<150/90
<135/85
<130/80
C. ISHIB are the treatment guidelines for AA patients. The goal here would be <135/85, more stringent control bc at higher risk. For secondary prevention, AKA already has clinical CVD, preclinical CVD, or TOD, goal is <130/80.

24. AR is a 38 yo AAF presenting to the clinic today for a regular check-up. She has a PMH of T2DM and HLD. Her BP reading today is 153/90, and you note that her BP was 145/89 at her previous visit. The physician diagnoses AR with hypertension.
What would be the best initial treatment option for this patient based on JNC8?
Amlodipine 5 mg QDay
Lisinopril 10 mg Qday
Metoprolol tartrate 25 mg BID
Clonidine 0.1 mg QID A
Thiazide or CCB are indicated 1st line in AA patients in most guidelines (JNC8, ISHIB, ASH/ISH)
ACEI/ARB could be considered based on ASH/ISH or ADA guidelines, 1st line in DM.
not typically 1st line in AA because don’t work as well physiologically (low-renin state)
Beta blockers are not 1st line unless there is some compelling indication
Alpha2 blockers have some pretty bad side effects (neurologic) so never 1st line. Only in refractory probably.
What are some important counseling points with DHP CCB? Side effects?

25. AR is a 38 yo AAF presenting to the clinic today for a regular check-up. She has a PMH of T2DM and HLD. Her BP reading today is 153/90, and you note that her BP was 145/89 at her previous visit. The physician diagnoses AR with hypertension.
AR is placed on thiazide monotherapy and comes back after 1 month for a follow-up evaluation. Her BP is 145/90. The physician decides to alter her regimen and asks for your suggestion. Which of the following combinations would you recommend?
Amlodipine 5 mg Qday + lisinopril 10 mg Qday
Amlodipine 5 mg Qday + diltiazem 90 mg BID
Lisinopril 10 mg Qday + valsartan 80 mg QD
Amlodipine 10 mg BID + metoprolol 25 mg BID A
Adding on a 2nd drug at a lower dose is a good option, and lisinopril is a good choice because this patient has DM! ADA and ASH/ISH guidelines would approve.
this combo also lowers mortality more than ACEI/ARB + thiazide in a patient with DM or HLD (thiazides you have to watch glucose and lipids)
Two CCB together is not the best choice, since we want combinations of drug with different mechanisms of action
You can NEVER use ACEI/ARB together. The benefits do not outweigh the risks associated! (hyperkalemia, renal dys)
And we want to exhaust all our other indicated options before moving to a beta blocker for BP reduction
When initiating this patient on an ACEI, what are some SE we want to specifically warn her about? Hyperkalemia (irregular heartbeat, muscle spasms), kidney function (SCr will rise some, but should rise more than 30%. Also this patient should be counseled on NSAID use), cough, pregnancy!

26. ES is a 65 yo WM with PMH of HTN, T2DM, and ischemic stroke 3 years ago. He has been taking a medication regimen of ASA, atorvastatin, metformin, and amlodipine. He came in to clinic today because his BP has been running high over the past month, with weekly readings including 150/95, 148/100, 155/95, and 154/98.
What is ES’ BP treatment goal according to JNC8?
<140/90
<150/90
<135/85
<130/80 A.
This patient is over 60, but has DM! so he falls into the <140/90 category. Diabetic patients of any age.

27. ES is a 65 yo WM with PMH of HTN, T2DM, and ischemic stroke 3 years ago. He has been taking a medication regimen of ASA, atorvastatin, metformin, and amlodipine. He came in to clinic today because his BP has been running high over the past month, with weekly readings including 150/95, 148/100, 155/95, and 154/98.
What is ES’ BP treatment goal based on ACC/AHA/ASH guidelines?
<140/90
<150/90
<135/85
<130/80 D.
These are special indication guidelines for CAD (TIA, stroke, PAD, AAA abdominal aortic aneurysm, post-MI).
Just goes to show that one set of guidelines might not always show the entire picture, and you have to use clinical judgment.

28. ES is a 65 yo WM with PMH of HTN, T2DM, and ischemic stroke 3 years ago. He has been taking a medication regimen of ASA, atorvastatin, metformin, and amlodipine. He came in to clinic today because his BP has been running high over the past month, with weekly readings including 150/95, 148/100, 155/95, and 154/98.
Which of the following additions to ES’ medication regimen would provide the most benefit?
Thiazide + beta blocker
Alpha blocker
aldosterone antagonist
Thiazide + ACEI
D. The thiazide is indicated for stroke protection in JNC7, and ACEI is indicated by ASH/ISH. You can add just one for benefit or add both at low doses.
ACC/AHA/ASH guidelines indicate both thiazides and ACEI for stroke/TIA benefit
Is amlodipine an appropriate first line agent to have initiated this patient on? Sure, JNC8 = thiazide/CCB/ACEI/ARB with equal evidence, ASH/ISH prefers thiazide/CCB if >60.
JNC7 and ACC/AHA/ASH would have preferred initiating a thiazide in the patient first line

29. WD is a 78 yo patient with recent diagnosis of HRrEF
WD is a 78 yo patient with recent diagnosis of HRrEF. He has been on a medication regimen for his HTN including amlodipine, HCTZ, and lisinopril. His doctor has optimized all doses of his current BP medications.
What is this patient’s BP treatment goal based on ACC/AHA HF guidelines?
<140/90
<150/90
<135/85
<130/80
D. So the official HF guidelines say to titrate therapy to maintain SBP<130. for increased risk of Stage A HF should maintain BP at <130/80

30. WD is a 78 yo patient with recent diagnosis of HRrEF
WD is a 78 yo patient with recent diagnosis of HRrEF. He has been on a medication regimen for his HTN including amlodipine, HCTZ, and lisinopril. His doctor has optimized all doses of his current BP medications.
What medication would you consider adding to WD’s current regimen to reduce mortality?
Prazosin
Hydralazine
Carvedilol
Aliskiren
C. carvedilol is a beta blocker which is always indicated for patients with HF. Ensure that he is not bradycardic before initiating, and also make sure to monitor that BP does not fall too low. You’ll talk a lot more about this with Dr. Parker when he does HF

31. BN is a 58 yo WM presenting to clinic today with elevated BP
BN is a 58 yo WM presenting to clinic today with elevated BP. He has been monitoring his BP with his pharmacist over the past month, and has recorded the three following readings this week: 167/98, 170/100, 162/100. His pharmacist recommended that he seek treatment for these readings. BN has a PMH of HLD for which he takes atorvastatin and mild arthritic pain in his hands for which he takes ibuprofen 600 mg about four times per week. He smokes about ½ ppd, and tries to stay active by walking around his local mall every Thursday.
What is the most appropriate medication regimen to initiate at this time according to JNC8?
Lisinopril + amlodipine
Losartan
Atenolol + amlodipine
HCTZ + nicardipine
>20 above his goal (<140/90) so we initiate combo therapy right away
D. ACEI/ARB, thiazide, CCB combo, no compelling indications here so really any three. Why wouldn’t we choose A?? He takes NSAIDs four times per week! For a patient who has arthritis and NSAID therapy is a mainstay of their treatment, an ACEI would not necessarily be the best option for kidney function.

32. BN is a 58 yo WM presenting to clinic today with elevated BP
BN is a 58 yo WM presenting to clinic today with elevated BP. He has been monitoring his BP with his pharmacist over the past month, and has recorded the three following readings this week: 167/98, 170/100, 162/100. His pharmacist recommended that he seek treatment for these readings. BN has a PMH of HLD for which he takes atorvastatin and mild arthritic pain in his hands for which he takes ibuprofen 600 mg about four times per week. He smokes about ½ ppd, and tries to stay active by walking around his local mall every Thursday.
What would be the most appropriate medication regimen to initiate according to ASH/ISH?
Amlodipine + chlorthalidone
Amlodipine + lisinopril
Eplerenone + losartan
HCTZ + hydralazine
Stage 2, so we initiate combo therapy
B. ASH/ISH with combo therapy recommends that you initiate CCB OR thiazide, + ACEI OR ARB. CCB + thiazide combo is not one of the initial recommended treatments unless the patient is black.

33. BN is a 58 yo WM presenting to clinic today with elevated BP
BN is a 58 yo WM presenting to clinic today with elevated BP. He has been monitoring his BP with his pharmacist over the past month, and has recorded the three following readings this week: 167/98, 170/100, 162/100. His pharmacist recommended that he seek treatment for these readings. BN has a PMH of HLD for which he takes atorvastatin and mild arthritic pain in his hands for which he takes ibuprofen 600 mg about four times per week. He smokes about ½ ppd, and tries to stay active by walking around his local mall every Thursday.
If BN were an AAM instead of a WM, and we decided to use ISHIB guideline-based treatment, what would be the most appropriate option?
Losartan + chlorthalidone
HCTZ + amlodipine
Lisinopril + spironolactone
Hydralazine + chlorthalidone
We need combo therapy since this patient is >15/10 above goal (<135/85)
ISHIB recommends CCB + RAS blocker OR thiazide + RAS blocker as preferred therapy. What if this patient had previously been on lisinopril and experienced angioedema? We would use an alternative therapy like a thiazide + CCB.
What if this patient were AAM and we were basing therapy on JNC8 guidelines? Thiazide + CCB is preferred.

34. BN is a 58 yo WM presenting to clinic today with elevated BP
BN is a 58 yo WM presenting to clinic today with elevated BP. He has been monitoring his BP with his pharmacist over the past month, and has recorded the three following readings this week: 167/98, 170/100, 162/100. His pharmacist recommended that he seek treatment for these readings. BN has a PMH of HLD for which he takes atorvastatin and mild arthritic pain in his hands for which he takes ibuprofen 600 mg about four times per week. He smokes about ½ ppd, and tries to stay active by walking around his local mall every Thursday.
What lifestyle recommendations can we make for this patient?
Smoking, NSAIDs, increase exercise. If he is overweight, we can recommend weight loss to reduce BP. Diet (low Na, DASH)

35. HG is a 29 yo AAF with PMH of stage 3 CKD
HG is a 29 yo AAF with PMH of stage 3 CKD. She was recently diagnosed with HTN, and her physician asks you for a recommendation on which medication to initiate. Her labs today include: K 4.5, CrCl <40, urine albumin excretion 80 mg/d.
According to KDIGO, what would be the most appropriate medication for this patient?
Spironolactone
Losartan
Aliskiren
Chlorthalidone
B- KDIGO recommends that if the urine albumin excretion is >30 in a 24 hr period, then the patient should be placed on an ACEI/ARB for renal protection.
ADA recommends that if urine alb excretion:Cr ratio >30, ACEI/ARB therapy.
What would we need to counsel her on if we initiate losartan? hyperK, renal function, angioedema!
Based on JNC8, what would be the recommended initial treatment for this patient? ACEI/ARB because CKD

36. JR is a 55 yo WM diagnosed with HTN 1 year ago
JR is a 55 yo WM diagnosed with HTN 1 year ago. He is currently taking a regimen of lisinopril 10 mg Qday, amlodipine 5 mg BID, and HCTZ 25 mg Qday. His blood pressure today is 150/95 with a repeat reading of 148/90. He has been compliant with his medications and lifestyle changes, but his BP is still above goal. As a pharmacist, what are some recommendations that you can make that will help JR achieve his BP goal?
Optimize doses. Can titrate up on lisinopril and amlodipine, and HCTZ if you want.
Change the medications. Is HCTZ the best thiazide? NO- use chlorthalidone instead.
Add another agent: beta blocker, aldosterone antagonist, vasodilator, etc. make sure to consider relevant SE and drug interactions. Does risk>benefit?

37. Questions?