What is the appropriate management for a 44-year-old patient with a history of hypertension, hyperlipidemia, and status post (after) prostatectomy presenting for a yearly medical examination?

From the Guidelines

This 44-year-old patient with hypertension, hyperlipidemia, and history of prostatectomy should receive a comprehensive annual exam focusing on these specific conditions, with a priority on lifestyle modifications and evidence-based pharmacological interventions to minimize morbidity, mortality, and improve quality of life. For hypertension management, I recommend monitoring blood pressure with a goal of <130/80 mmHg, as suggested by the most recent guidelines 1. First-line medications include ACE inhibitors (like lisinopril 10-20mg daily), ARBs (such as losartan 50-100mg daily), calcium channel blockers (amlodipine 5-10mg daily), or thiazide diuretics (hydrochlorothiazide 12.5-25mg daily).

• Key considerations for this patient include:
  • Lifestyle modifications such as a heart-healthy diet, regular exercise (150 minutes of moderate activity weekly), weight management, sodium restriction (<2300mg daily), and alcohol moderation
  • Urinary function assessment, including screening for incontinence and erectile dysfunction, with pelvic floor exercises potentially helping with urinary control issues
  • PSA monitoring should continue even after prostatectomy, with levels expected to be undetectable (<0.1 ng/mL)
  • For hyperlipidemia, a moderate-intensity statin like atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily is recommended, with a goal LDL <100 mg/dL, as supported by guidelines 1
  • Regular assessment of lipid profiles and adjustment of lipid-lowering therapy as needed, considering the patient's overall cardiovascular risk profile
  • Emphasis on weight management and physical activity for patients with high triglycerides or low HDL-C, as outlined in guidelines 1
  • Consideration of omega-3 fatty acids as an adjunct for high triglycerides, as suggested by some guidelines 1
  • Regular monitoring of blood pressure, lipid profiles, and other cardiovascular risk factors to guide therapy and minimize the risk of cardiovascular events.

From the FDA Drug Label

Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than 1 drug to achieve blood pressure goals.

The patient has a history of hypertension and hyperlipidemia.

• Lisinopril can be used to treat hypertension.
• The use of lisinopril in patients with hyperlipidemia is supported by the fact that control of high blood pressure should be part of comprehensive cardiovascular risk management, including lipid control.
• The patient's history of status post prostatectomy is not directly relevant to the treatment of hypertension or hyperlipidemia with lisinopril or atorvastatin 2.

From the Research

Patient's Medical History

The patient has a history of:

• Hypertension
• Hyperlipidemia
• Status post prostatectomy

Treatment of Hypertension

According to 3, first-line therapy for hypertension is lifestyle modification, including:

• Weight loss
• Healthy dietary pattern with low sodium and high potassium intake
• Physical activity
• Moderation or elimination of alcohol consumption If drug therapy is required, first-line therapies are:
• Thiazide or thiazide-like diuretics
• Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers
• Calcium channel blockers

Comparison of Antihypertensive Therapies

A study by 4 compared the effects of chlorthalidone, amlodipine, and lisinopril on cardiovascular disease outcomes, and found that:

• Thiazide-type diuretics are superior in preventing major forms of cardiovascular disease
• Chlorthalidone had a lower rate of heart failure compared to amlodipine and lisinopril
• Lisinopril had a higher rate of combined cardiovascular disease, stroke, and heart failure compared to chlorthalidone

Physical Activity as a Critical Component of Treatment

According to 5, physical activity is a critical component of first-line treatment for elevated blood pressure or cholesterol, and:

• Increasing physical activity has extensive benefits, including improving blood pressure and blood cholesterol
• Physical activity assessment and prescription are an excellent lifestyle behavior treatment option for all patients

Angiotensin-Converting Enzyme Inhibitors in Hypertension

A review by 6 found that:

• There is no difference in efficacy between angiotensin receptor blockers and angiotensin-converting enzyme inhibitors with regard to blood pressure and outcomes
• Angiotensin receptor blockers have fewer adverse events compared to angiotensin-converting enzyme inhibitors

Hyperlipidemia Treatment

According to 7, the use of statins to treat hyperlipidemia is widely accepted and recommended, but:

• Statin use is associated with myalgias, myopathy, musculoskeletal injury, liver injury, and increased diabetes risk
• The evidence for non-statin treatments is mixed, with some treatments reducing cardiovascular events and others showing no benefit