January 22nd, 2014

Prevention Guidelines in Practice: Vignette 1

This vignette is the first in our series “Making Sense of the New Prevention Guidelines — The View from Clinical Practice

I received this email from a 71-year-old gentleman in Utah who takes lisinopril 40 mg daily for hypertension and has never experienced an adverse event. He is a nonsmoker, exercises regularly, and has a normal body-mass index. He attached to the email a log of his systolic BP results, which have ranged from 130 to 151 mm Hg. Here is an excerpt from his message:

I would like to get your reaction to the new BP guidelines just published in JAMA. …I am quite confident that I could keep my systolic under the new guideline of 150 without medication. Please see my attached log — this morning it was 126. The side effects of a dry throat are bothersome and interfere with my sleep on occasion. I would like to propose that I cut my [lisinopril] dose in half to 20 mg/day, if not eliminate it all together.

  • How would you respond to this patient?
  • Have the guidelines and the related debate influenced how you counsel your patients and conduct your practice?

5 Responses to “Prevention Guidelines in Practice: Vignette 1”

  1. Enrique Guadiana, Cardiology says:

    If the patient has no other risk factor or evidence of any organ damage, specially If the fundoscoptic exam is normal I don’t have objections to try it. At 71, I think this gentleman deserve to have quality of life.

  2. David Powell , MD, FACC says:

    For me, the possibility of a medication-related side-effect mandates a switch, perhaps to an ARB. As for the “new goal”, I think he is a bit younger than the HYVET group, and I would stick with SBP 135 mmHG (I made this up), or average SBP on ABPM <135 mmHg.
    As well documented in this forum, there is not much guidance on home BP goals.

  3. would like to see his complete log of BP measurements, atleast during last fortnight or month. he is symptomatic ( dryness of throat)?? needs ENT workup.

    else, i would suggest lowering of lisinopril to 20 mg/day.

    he is 71 yrs old, follows LSM but also at equal risk of fall ( Orthostatic) & injuries. therefore a more liberal target of 150/90 looks good.

  4. Fabio Alban, MD says:

    I believe that ABPM could be helpful to answer the question and fit the treatment.

  5. I would tell the patient not to believe everything he reads! I’m uneasy about the hypertension guidelines in general—the “breakaway” from the other groups and the apparent dissention on the committee erode my confidence a bit. In general I agree with a more lenient target for older patients, on an individualized basis–particularly when orthostatic symptoms are present. This patient is otherwise healthy and vigorous and has no significant side effects so I would advise to stay on medications to lower his stroke risk. I doubt his BP would be adequately controlled with lifestyle changes alone.