Management of Palpitations, Chest Pain, and Dizziness with Worsening Hypertension
This patient requires immediate cardiovascular workup with ECG and cardiac monitoring, discontinuation of ibuprofen, and optimization of her hypertension regimen by adding a thiazide diuretic as the third agent.
Immediate Diagnostic Evaluation
Obtain a 12-lead ECG immediately to evaluate for arrhythmias, as palpitations with chest pain and dizziness warrant urgent cardiac assessment 1, 2. The ECG is the gold standard for diagnosing cardiac arrhythmias in patients presenting with palpitations 1.
- Arrange ambulatory ECG monitoring (24-48 hour Holter or event monitor) if the initial ECG is normal, since intermittent symptoms over 2 weeks suggest paroxysmal arrhythmias that may not be captured on a single ECG 1, 2.
- Assess for structural heart disease given her multiple cardiovascular risk factors (hypertension, diabetes, hyperlipidemia), as premature ventricular contractions and other arrhythmias can indicate underlying cardiac pathology 3, 4.
- Rule out acute coronary syndrome in this 49-year-old diabetic woman with chest pain, as diabetes is a major risk factor and women may present atypically 3.
Critical Medication Review
Discontinue ibuprofen immediately, as NSAIDs significantly interfere with blood pressure control and can worsen hypertension 5. NSAIDs antagonize the effects of ACE inhibitors and diuretics, contributing to her worsening blood pressure from 142/90 to 153/105 mmHg 5.
- NSAIDs should be avoided in hypertensive patients on ACE inhibitor therapy, as they reduce antihypertensive efficacy and increase cardiovascular risk 5.
Hypertension Management
Add a thiazide or thiazide-like diuretic as the third antihypertensive agent to achieve guideline-recommended triple therapy 3, 5. Her blood pressure of 153/105 mmHg represents stage 2 hypertension requiring immediate intensification 5.
- Start chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes) or hydrochlorothiazide 25 mg daily if chlorthalidone is unavailable 5.
- The combination of ACE inhibitor + thiazide diuretic + calcium channel blocker represents guideline-recommended triple therapy with complementary mechanisms targeting renin-angiotensin system blockade, volume reduction, and vasodilation 3, 5.
- Target blood pressure is <140/90 mmHg minimum, ideally <130/80 mmHg given her diabetes and cardiovascular risk factors 3, 5.
Rationale for Adding Diuretic
The European Society of Cardiology recommends initiating pharmacological treatment with the combination of a RAAS blocker with a calcium channel blocker or thiazide/thiazide-like diuretic 3. Since she is already on lisinopril-hydrochlorothiazide 20/12.5 mg, the hydrochlorothiazide component may be suboptimal at this dose for her current blood pressure elevation 5.
- Consider increasing to a more effective thiazide regimen or switching to chlorthalidone for superior 24-hour blood pressure control 5.
- Monitor serum potassium and creatinine 2-4 weeks after diuretic adjustment to detect hypokalemia or changes in renal function 5.
Diabetes and Cardiovascular Risk Management
Her current diabetes regimen with Trulicity (dulaglutide) 1.5 mg and metformin 500 mg is appropriate, as GLP-1 receptor agonists like dulaglutide are recommended in patients with type 2 diabetes and cardiovascular risk factors to reduce cardiovascular events 3.
- Dulaglutide is recommended in patients with T2DM at very high/high cardiovascular risk to reduce cardiovascular events 3.
- Consider adding an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) if not contraindicated, as these agents reduce cardiovascular events and lower the risk of heart failure hospitalization in diabetic patients 3.
Lipid Management
Increase atorvastatin from 10 mg to at least 40-80 mg daily, as patients with diabetes at very high cardiovascular risk require intensive statin therapy to achieve LDL-C target of <55 mg/dL (<1.4 mmol/L) with at least 50% reduction from baseline 3.
- If LDL-C target is not reached with maximum tolerated statin, add ezetimibe 10 mg daily 3.
Symptom-Specific Considerations
Palpitations with dizziness and chest pain require exclusion of serious arrhythmias, particularly given her uncontrolled hypertension and diabetes 1, 2. These symptoms are potentially more serious when associated with dizziness 2.
- Assess for orthostatic hypotension by measuring blood pressure supine and after standing for 3 minutes, as ACE inhibitors and diuretics can cause orthostatic changes 6, 7.
- Home blood pressure monitoring or 24-hour ambulatory monitoring should be considered to assess for blood pressure variability 6.
- Attempts to diagnose structural heart disease should be considered in diabetic patients with frequent premature ventricular contractions 3.
Lifestyle Modifications
Reinforce sodium restriction to <2 g/day, which provides 5-10 mmHg systolic blood pressure reduction 6, 5.
- Regular physical activity, weight management, limiting alcohol consumption, and reducing sugar consumption are recommended to achieve better blood pressure control 6.
- DASH diet implementation can reduce systolic and diastolic blood pressure by 11.4 and 5.5 mmHg respectively 5.
Follow-up and Monitoring
Schedule follow-up within 2-4 weeks to assess response to medication adjustment and review ambulatory ECG monitoring results 6, 5.
- Reassess blood pressure with goal of achieving target within 3 months of treatment modification 5.
- Educate the patient about warning signs that warrant immediate medical attention, including syncope, severe chest pain, or worsening dyspnea 6.
- If blood pressure remains uncontrolled after optimizing triple therapy, consider adding spironolactone 25-50 mg daily as the preferred fourth-line agent for resistant hypertension 5.
Critical Pitfalls to Avoid
Do not delay cardiac workup in a diabetic patient with palpitations, chest pain, and dizziness, as diabetes increases cardiovascular risk and women may present atypically 3.