From the Guidelines
The patient's uncontrolled hypertension and anxiety disorder require immediate attention, and management should focus on lifestyle modifications and potential medication adjustments, as suggested by the 2018 American College of Cardiology/American Heart Association hypertension guideline 1. The patient is a recently released inmate establishing care for anxiety and hypertension management. He experiences constant anxiety that worsens in large groups and is having difficulty adjusting to post-prison life. Despite attending twice-weekly counseling through probation, his anxiety remains problematic. He previously tried buspirone (Buspar) but discontinued it due to worsening anxiety. His current medications include lisinopril 40 mg and amlodipine 5 mg for hypertension, which is currently uncontrolled with elevated blood pressure readings in the office. Contributing lifestyle factors include a new relationship with frequent restaurant dining and decreased physical activity. The patient denies suicidal/homicidal ideation, auditory hallucinations, and substance use. Key considerations for management include:
- Lifestyle interventions, such as weight reduction, reduction in sodium chloride intake, restriction of alcohol consumption, and regular physical activity, as recommended by the European guidelines on cardiovascular disease prevention in clinical practice 1
- Potential medication adjustments, including maximization of diuretic therapy, addition of a mineralocorticoid receptor antagonist, or referral to a hypertension specialist, as suggested by the 2018 American College of Cardiology/American Heart Association hypertension guideline 1
- Addressing the patient's anxiety disorder, potentially through alternative medications or therapies, given the discontinuation of buspirone due to worsening anxiety. The patient's care plan should prioritize evidence-based management of his hypertension and anxiety disorder, with a focus on lifestyle modifications and potential medication adjustments, to improve his overall quality of life and reduce the risk of cardiovascular complications, as emphasized by the 2014 standards of medical care in diabetes 1.
From the Research
History of Present Illness (HPI)
The patient presents with a history of constant anxiety that worsens in large groups of people. He has recently been released from prison and is struggling to adjust to everyday life. The patient is currently attending counseling sessions twice a week as part of his probation.
Medication History
- The patient has tried Buspar in the past but reports worsening anxiety and has since stopped taking the medication.
- His current medication regimen includes:
- Lisinopril 40 mg
- Amlodipine 5 mg
Recent Developments
- The patient's blood pressure is elevated in the office, which he attributes to finding a new girlfriend and eating out frequently.
- He also reports a decrease in physical activity.
- The patient denies any suicidal or homicidal ideation, auditory hallucinations, or use of alcohol or drugs.
Relevant Studies
- Cognitive-behavioral therapy (CBT) has been shown to be effective in treating anxiety disorders, including social anxiety disorder 2.
- Other psychotropic agents, such as beta-blockers, benzodiazepines, and anticonvulsants, may also be useful in managing social anxiety disorder 3.
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been found to be effective in treating anxiety disorders, with higher doses of SSRIs associated with greater symptom improvement 4.
- Patient self-reported symptoms are crucial in identifying and monitoring anxiety disorders, and various instruments are available to assess anxiety 5.
- Non-pharmaceutical interventions, such as music, CBT, relaxation, and massage, have been shown to be effective in reducing anxiety in patients undergoing medical or dental procedures 6.