What is the next step for a patient who developed a hypertensive response to exercise at 2 minutes, was switched to Lexiscan (regadenoson), and still has elevated systolic blood pressure in the 170s after reversal, despite taking metoprolol (Metoprolol) 50mg, with an initial systolic blood pressure of 144?

From the Guidelines

The patient's blood pressure should be closely monitored, and additional antihypertensive medication should be considered if her systolic pressure remains above 170mmHg after 30 minutes, with a potential addition of a short-acting calcium channel blocker or a vasodilator like hydralazine 10mg IV, as per the 2024 ESC guidelines for hypertension management 1. The patient's current blood pressure of 170s systolic is concerning, and given that she has already taken metoprolol 50mg, it is essential to consider adding another agent to help lower her blood pressure.

• The 2024 ESC guidelines recommend combining beta-blockers with other major BP-lowering drug classes when there are other compelling indications for their use, such as angina or heart failure 1.
• Since the patient has already taken metoprolol, a beta-blocker, adding a short-acting calcium channel blocker like nifedipine 10mg or a vasodilator such as hydralazine 10mg IV could be considered if her systolic pressure remains elevated.
• It is also crucial to ensure the patient is comfortable, in a quiet environment, and encourage slow, deep breathing, which may help reduce her blood pressure.
• The patient's vital signs should be monitored every 15 minutes until her blood pressure stabilizes to safer levels, ideally below 160/100mmHg.
• The hypertensive response during the stress test was likely due to increased catecholamine release and peripheral vasoconstriction during exercise, which may have been exacerbated by the Lexiscan (regadenoson) 1.
• If the patient's blood pressure does not respond to these interventions or continues to rise, consider transferring her to an emergency department for more intensive management.
• Additionally, ensure follow-up with her primary care physician within a week to reassess her chronic hypertension management, as this episode suggests her current regimen may need adjustment, considering the recommendations for combination BP-lowering treatment and preferred combinations of a RAS blocker with a dihydropyridine CCB or diuretic 1.

From the Research

Patient's Condition

• The patient had a hypertensive response to exercise at 2 minutes, with systolic blood pressure (BP) initially at 144.
• The patient was switched to Lexiscan, but after reversal, the BP still remains in the 170s systolic.
• The patient was given metoprolol 50mg.

Treatment Options

• According to the study 2, metoprolol is effective in treating mild to moderate hypertension, but its effectiveness in severe hypertension is uncertain.
• The study 3 found that IV hydralazine resulted in a significant drop in BP, while metoprolol did not lower BP compared to no treatment.
• The study 4 suggests that amlodipine is effective in lowering BP and controlling BP variability, and it may be a good option for patients with hypertension.
• The study 5 found that combining amlodipine with metoprolol improved hemodynamics and ventricular function in patients with hypertension complicated by heart failure.

Next Steps

• Consider adding amlodipine to the patient's treatment regimen, as it may help to lower BP and improve hemodynamics 4, 5.
• Monitor the patient's BP and adjust the treatment plan as needed.
• Consider alternative treatment options, such as IV hydralazine, if the patient's BP remains elevated 3.