What is the assessment and plan for this patient?

From the Guidelines

The patient's current management plan, which includes a phase 2 cardiac rehabilitation program, strength training, and education on medications, should be continued and optimized to improve her overall quality of life and reduce morbidity and mortality risk. The decision to stop taking ibuprofen and aspirin should be reassessed and discussed with the patient's PCP to ensure that the benefits of discontinuing these medications outweigh the risks, considering her history of atherosclerotic cardiovascular disease and multimorbidity 1.

The patient's PCP should continue to help her manage her knee, hip, and back pain, as well as her type 2 diabetes, using a comprehensive and patient-centered approach that takes into account her individual preferences, values, and goals 1. This approach should include regular reassessments of her medication list, lifestyle, and health priorities to ensure that her treatment plan is optimized and aligned with her needs.

Key components of her management plan should include:

• Regular medication reconciliation to ensure that she is taking her medications as prescribed and to minimize the risk of adverse interactions or effects
• Ongoing education and support to help her manage her chronic conditions and improve her self-efficacy and health outcomes
• A patient-centered approach that prioritizes her individual needs, preferences, and values, and that incorporates her family and caregivers as needed
• Regular monitoring and reassessment of her health status, including her cardiovascular risk factors, diabetes control, and pain management, to ensure that her treatment plan is optimized and effective.

By continuing and optimizing her current management plan, the patient's quality of life and health outcomes can be improved, and her risk of morbidity and mortality can be reduced 1.

From the FDA Drug Label

USE IN SPECIFIC POPULATIONS 8. 1 Pregnancy Pregnancy Category D Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. When pregnancy is detected, discontinue lisinopril as soon as possible. 8. 3 Nursing Mothers Milk of lactating rats contains radioactivity following administration of 14C lisinopril. It is not known whether this drug is excreted in human milk Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ACE inhibitors, a decision should be made whether to discontinue nursing or discontinue lisinopril, taking into account the importance of the drug to the mother. 8. 4 Pediatric Use Antihypertensive effects and safety of lisinopril have been established in pediatric patients aged 6 to 16 years No relevant differences between the adverse reaction profile for pediatric patients and adult patients were identified. Safety and effectiveness of lisinopril have not been established in pediatric patients under the age 6 or in pediatric patients with glomerular filtration rate < 30 mL/min/1.73 m2 8. 5 Geriatric Use No dosage adjustment with lisinopril is necessary in elderly patients. 8.6 Race ACE inhibitors, including lisinopril, have an effect on blood pressure that is less in black patients than in non-blacks. 8. 7 Renal Impairment Dose adjustment of lisinopril is required in patients undergoing hemodialysis or whose creatinine clearance is ≤ 30 mL/min.

To create an assessment and plan for this patient, we need to consider the following key points:

• Pregnancy: Discontinue lisinopril as soon as possible if pregnancy is detected.
• Nursing mothers: Decide whether to discontinue nursing or discontinue lisinopril, considering the importance of the drug to the mother.
• Pediatric use: Established safety and efficacy in patients aged 6 to 16 years, but not in those under 6 years or with glomerular filtration rate < 30 mL/min/1.73 m2.
• Geriatric use: No dosage adjustment necessary in elderly patients.
• Renal impairment: Dose adjustment required in patients undergoing hemodialysis or with creatinine clearance ≤ 30 mL/min.

Assessment:

• Evaluate the patient's renal function and blood pressure.
• Consider the patient's age, pregnancy status, and nursing status.
• Assess the patient's overall health and medical history.

Plan:

• Monitor the patient's blood pressure, renal function, and overall health.
• Adjust the dose of lisinopril as needed based on the patient's renal function and blood pressure.
• Educate the patient on the potential risks and benefits of lisinopril, especially in pregnant or nursing women.
• Consider alternative treatments if the patient is pregnant, nursing, or has significant renal impairment. 2

From the Research

Patient Assessment

• The patient's blood pressure needs to be monitored and managed to prevent cardiovascular complications of hypertension.
• The patient's medical history, including any previous hypertension treatments, should be taken into account when creating a treatment plan.
• The patient's lifestyle, including diet and exercise habits, should also be considered when creating a treatment plan.

Treatment Plan

• Combination therapy with agents having complementary mechanisms of action, such as a calcium channel blocker and an angiotensin II-receptor blocker, may be a useful therapeutic option for patients with stage 2 hypertension 3.
• The combination of amlodipine and valsartan has been shown to be well tolerated and efficacious in reducing blood pressure in patients with stage 2 hypertension 3.
• Other antihypertensive drug combinations, such as lisinopril and hydrochlorothiazide, may also be effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension 4.
• Amlodipine has been shown to be effective in minimizing blood pressure variability, which may be an important factor in preventing cardiovascular complications of hypertension 5.

Medication Options

• Amlodipine: a calcium channel blocker that has been shown to be effective in reducing blood pressure and minimizing blood pressure variability 3, 5.
• Valsartan: an angiotensin II-receptor blocker that has been shown to be effective in reducing blood pressure when used in combination with amlodipine 3.
• Lisinopril: an angiotensin-converting enzyme inhibitor that has been shown to be effective in reducing blood pressure, but may not be superior to diuretics for the long-term prevention of major cardiovascular complications of hypertension 6, 7.
• Hydrochlorothiazide: a diuretic that has been shown to be effective in reducing blood pressure when used in combination with other antihypertensive medications 3, 4.

Monitoring and Follow-up

• The patient's blood pressure should be monitored regularly to assess the effectiveness of the treatment plan.
• The patient's lifestyle, including diet and exercise habits, should be monitored and adjusted as needed to support the treatment plan.
• The patient should be followed up with regularly to assess for any potential side effects of the medication and to make any necessary adjustments to the treatment plan.