What management plan should be recommended for a patient with ischemic heart disease (IHD), hypertension (HTN), and an overdue blood test, who is currently asymptomatic but has hypertension?

Management of Hypertension in a Patient with Ischemic Heart Disease

For this patient with ischemic heart disease (IHD), hypertension (BP 149/88), and an overdue blood test, the blood pressure should be lowered to a target of <130/80 mmHg using a combination of lifestyle modifications and optimization of current antihypertensive medications.

Blood Pressure Assessment and Classification

The patient's current blood pressure of 149/88 mmHg classifies as Stage 2 hypertension according to the 2017 ACC/AHA guidelines 1. This is concerning given the patient's history of:

• Ischemic heart disease
• Previous myocardial infarction 17 years ago with stent placement
• Current antihypertensive therapy that is not achieving target BP

Management Approach

Immediate Management

1. Blood Test Priority

   • Schedule the overdue blood test immediately
   • Include comprehensive metabolic panel, lipid profile, and HbA1c
   • These tests are essential for risk stratification and medication management

2. Blood Pressure Management

   • According to the 2017 ACC/AHA guidelines, patients with stage 2 hypertension should be evaluated within 1 month of diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy initiated (with 2 agents of different classes), and have a repeat BP evaluation in 1 month 1
   • Current regimen includes metoprolol and doxazosin, which may need optimization

Medication Optimization

1. Current Medication Review

   • Metoprolol: Appropriate for IHD but may need dose adjustment; beta-blockers are first-line therapy for patients with IHD and hypertension 1
   • Doxazosin: Alpha-blockers are generally not preferred first-line agents for hypertension in patients with heart failure risk 1
   • Aspirin: Continue as secondary prevention for IHD
   • Statin: Continue for lipid management and cardiovascular risk reduction
   • Omeprazole: Continue for GI protection with aspirin therapy

2. Medication Adjustments

   • Consider adding an ACE inhibitor or ARB: These are recommended as part of the core regimen for patients with IHD and hypertension 1
   • Consider adding a thiazide diuretic: The combination of a β-blocker, ACE inhibitor or ARB, and a thiazide diuretic is recommended for patients with IHD 1
   • Metoprolol dose: May need to be optimized, but avoid abrupt discontinuation as this can exacerbate angina or precipitate MI in patients with coronary artery disease 2

Lifestyle Modifications

1. Physical Activity

   • Continue to encourage regular cycling
   • Aim for at least 30 minutes of moderate-intensity activity daily 1

2. Dietary Recommendations

   • Sodium restriction to <5g/day
   • DASH diet (rich in fruits, vegetables, low-fat dairy products)
   • Limit alcohol consumption 1

3. Smoking Cessation

   • Reinforce importance of maintaining smoking cessation
   • Offer support for preventing relapse 1

Target Blood Pressure and Monitoring

1. BP Target

   • For patients with IHD: <130/80 mmHg 1, 3
   • Monitor for signs of myocardial ischemia if diastolic BP falls below 60 mmHg, especially in older patients 1

2. Follow-up Schedule

   • Repeat BP measurement within 2-4 weeks after medication adjustments
   • Once BP is controlled, follow up every 3-6 months
   • Regular cardiac risk assessment

Special Considerations

1. Caution with Diastolic BP

   • In older hypertensive individuals with wide pulse pressures, lowering SBP may cause very low DBP values (<60 mmHg)
   • This requires careful monitoring for signs of myocardial ischemia 1

2. Medication Interactions

   • Monitor for potential interactions between current medications
   • Beta-blockers like metoprolol can mask symptoms of hypoglycemia 2

3. Cardiovascular Risk Assessment

   • Complete a formal cardiovascular risk assessment using appropriate risk prediction models once blood tests are available 4

Conclusion

This patient requires prompt attention to blood pressure control given the history of IHD and current stage 2 hypertension. The management should focus on optimizing the antihypertensive regimen by considering the addition of an ACE inhibitor/ARB and possibly a thiazide diuretic, while continuing beta-blocker therapy. Regular follow-up and monitoring are essential to achieve and maintain the target BP of <130/80 mmHg while avoiding adverse effects.