What additional antihypertensive therapy is recommended for this patient with elevated blood pressure after hydralazine?

From the Guidelines

For this patient with elevated blood pressure after hydralazine, I recommend adding a calcium channel blocker like nicardipine, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. This patient has a history of hypertension, hyperlipidemia, coronary artery disease with stents, and a pacemaker, which increases the risk of cardiovascular complications. Given the patient's recent blood pressure of 175/83 after hydralazine, and 193/107 before that, it is crucial to achieve better blood pressure control to reduce the risk of cardiovascular events. Some key points to consider when selecting an additional antihypertensive agent include:

• The patient's medical history, including CAD, HTN, and HLD
• The potential for drug interactions with the patient's current medications
• The need for close monitoring of blood pressure and potential side effects
• The importance of selecting an agent that will not worsen the patient's existing conditions, such as heart failure or renal disease Considering these factors, nicardipine is a suitable option, as it is a calcium channel blocker that can be administered intravenously and has a relatively fast onset of action, with a usual dose range of 5 mg/h, increasing every 5 min by 2.5 mg/h to a maximum of 15 mg/h, as outlined in the guideline 1. Additionally, the patient's blood pressure should be closely monitored, and the dose of nicardipine should be adjusted accordingly to achieve a target blood pressure below 130/80 mmHg. It is also essential to consider the potential risks and benefits of other antihypertensive agents, such as sodium nitroprusside, nitroglycerin, and esmolol, and to select the most appropriate agent based on the patient's individual needs and medical history, as outlined in the guideline 1.

From the Research

Patient's Current Condition

The patient is currently experiencing abdominal pain and is scheduled for a colonoscopy tomorrow. The patient has a history of hypertension (HTN), hyperlipidemia (HLD), coronary artery disease (CAD) with stents, a pacemaker, and compartment syndrome with a previous fasciotomy. The patient's latest blood pressure reading is 175/83 mmHg, with a heart rate of 71 beats per minute after administration of hydralazine. The blood pressure was previously 193/107 mmHg.

Blood Pressure Management

• The patient's blood pressure is still elevated after hydralazine administration, but there is no complaint of chest pain.
• According to the study 2, intravenous hydralazine resulted in a significant drop in blood pressure following severe hypertension, with a reduction of 13 mmHg in mean arterial pressure, 18 mmHg in systolic blood pressure, and 11 mmHg in diastolic blood pressure.
• However, the study 3 suggests that intravenous hydralazine is commonly prescribed for non-urgent cases of hypertension in hospitalized patients, but its use may be associated with hypotension and may not be useful for treating hypertension in many cases.

Additional Antihypertensive Therapy

• Considering the patient's history of hypertension and current blood pressure reading, additional antihypertensive therapy may be necessary.
• The study 4 suggests that hydralazine, methyldopate, enalaprilat, and nicardipine are options for patients temporarily requiring intravenous medications for controlling chronic hypertension.
• The study 5 shows that hydralazine can increase cardiac output and reduce right ventricular end-diastolic pressure even when pulmonary arterial pressure remains unchanged.
• The study 6 found that the duration of hydralazine action in hypertension can vary, with a prolonged terminal phase of elimination.

Potential Next Steps

• Monitor the patient's blood pressure closely and consider additional antihypertensive therapy if necessary.
• Consult with the attending physician, Dr. Aurelio, to determine the best course of action for the patient's blood pressure management.
• Consider alternative antihypertensive medications, such as those mentioned in the study 4, if hydralazine is not effective or is associated with adverse effects 3, 2.