NSAIDs like Ibuprofen can interfere with antihypertensive medications, leading to increased blood pressure. NSAIDs reduce the renal prostaglandins that mediate vasodilation, causing sodium and water retention.
B. Lisinopril dose is too low: Although the dose could be titrated, the addition of Ibuprofen is a significant contributing factor.
C. HCTZ causing hypokalemia: Hypokalemia can occur with thiazides but is not the main cause here.
D. Non-adherence: There is no evidence provided for non-adherence.
Clinical Tip: Avoid chronic NSAID use in patients with hypertension; consider alternatives like acetaminophen for pain.
Carvedilol titration: In HFrEF, beta-blockers (Carvedilol, Metoprolol succinate) should be titrated to the target dose as tolerated to improve mortality and reduce hospitalizations. The patient is stable with a low-normal BP, making up-titration appropriate.
B. Discontinue Furosemide: Diuretics manage fluid status; discontinuation is inappropriate without signs of volume overload resolution.
C. Add Spironolactone: Spironolactone is indicated for HFrEF patients with EF ≤ 35% and persistent symptoms despite optimized therapy, which is not the case here.
D. Increase Lisinopril: ACE inhibitors are titrated gradually, but priority is given to beta-blocker titration to target doses.
Clinical Tip: Always titrate beta-blockers to target doses unless the patient is symptomatic or hypotensive.
Apixaban dosing adjustment is required when 2 out of 3 criteria are met:
Age ≥ 80 years
Weight ≤ 60 kg
Serum creatinine ≥ 1.5 mg/dL
In this case:
Age: 72 years (does not meet)
Weight: 48 kg (meets criterion)
Serum creatinine: 1.6 mg/dL (meets criterion)
Thus, the dose should be reduced to 2.5 mg BID.
Clinical Tip: Always monitor renal function and weight in older patients on direct oral anticoagulants (DOACs).
Empagliflozin (SGLT2 inhibitor) is indicated in patients with Type 2 Diabetes and albuminuria due to its renal protective effects and ability to lower cardiovascular risk.
B. Amlodipine: This calcium channel blocker lowers blood pressure but does not provide renal protection like SGLT2 inhibitors.
C. Pioglitazone: Increases risk of fluid retention and heart failure.
D. Sitagliptin: DPP-4 inhibitors improve glycemic control but lack renal and cardiovascular benefits.
Clinical Tip: SGLT2 inhibitors (e.g., Empagliflozin, Dapagliflozin) are preferred in diabetic patients with albuminuria.
Patients with CAD and a history of myocardial infarction should be on high-intensity statin therapy to reduce LDL to <70 mg/dL. Atorvastatin 40-80 mg or Rosuvastatin 20-40 mg is recommended.
B. Ezetimibe: Not first-line; it can be added if LDL goals are not achieved with statins alone.
C. Rosuvastatin 5 mg: This is a moderate-intensity dose and insufficient for secondary prevention.
D. Increase Metoprolol: No indication for beta-blocker dose increase; focus here is on lipid management.
Clinical Tip: In secondary prevention, prioritize high-intensity statins to lower LDL cholesterol aggressively.
