What is the best course of action for a 49-year-old patient with a history of hypertension (HTN) and a recent stroke, who has run out of medication for approximately one month and has not completed the recommended post-stroke follow-up testing with cardiology?

From the Guidelines

I strongly recommend refilling the patient's antihypertensive medications immediately and restarting them as soon as possible, with a target blood pressure of <130/80 mmHg, as recommended by 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. The patient's history of stroke and current uncontrolled hypertension put them at high risk for recurrent stroke, and prompt management of their blood pressure is crucial to reduce this risk.

• The patient should be prescribed their previous antihypertensive medication, likely an ACE inhibitor or ARB plus a diuretic, at the same doses, as these agents have been shown to be effective in secondary stroke prevention 1.
• The patient should also be counseled on the importance of medication adherence and completing recommended follow-up testing, including the previously ordered cardiology testing, such as an echocardiogram and carotid ultrasound, within the next week.
• Additionally, the patient should have a follow-up appointment within 2 weeks to monitor medication effectiveness and adherence. It's concerning that the patient has been without medication for a month following a recent stroke, which significantly increases their risk of a recurrent stroke.
• Stroke patients typically require aggressive secondary prevention with antiplatelet therapy and strict blood pressure control, and the patient should be considered for dual antiplatelet therapy with aspirin and clopidogrel, if not already prescribed. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline recommends aiming for a blood pressure target of <130/80 mmHg in patients with a history of stroke or TIA, and this should be the goal for this patient's treatment plan 1.

From the Research

Patient's Current Concern

The patient is in need of refills on their medication, having run out about a month ago. They have a history of hypertension (HTN) and had a stroke a week before Thanksgiving. The patient also has a cardiology follow-up post-stroke but has not completed the required testing.

Relevant Studies

• The study 2 from 1997 discusses the effectiveness of antihypertensive agents such as ACEIs, angiotensin II receptor antagonists, and calcium antagonists. It suggests that these agents are effective but should be considered alternative drugs for first-line therapy until randomized trials show they are at least as effective as diuretics and beta-blockers in preventing cardiovascular morbidity and mortality.
• A 2008 study 3 found that fixed-dosed combination regimens consisting of a calcium channel blocker and an angiotensin II type 1 receptor blocker are effective for managing hypertension, demonstrating better efficacy and being well-tolerated compared to individual agents.
• The 2018 review 4 compares outcomes and adverse events between ACE inhibitors and ARBs in patients with hypertension. It found no difference in efficacy between ARBs and ACE inhibitors regarding blood pressure and outcomes but noted that ACE inhibitors are associated with more adverse events like cough and angioedema.
• A 2014 systematic review 5 comparing ACE inhibitors and ARBs for primary hypertension found no evidence of a difference in total mortality or cardiovascular outcomes but noted that ARBs caused slightly fewer withdrawals due to adverse effects.
• A 2004 study 6 showed that initial combination therapy with an ACE inhibitor and a calcium channel blocker achieves superior blood pressure control compared to calcium channel blocker monotherapy in patients with stage 2 hypertension.

Key Points for Consideration

• The choice between ACE inhibitors and ARBs should consider the patient's specific conditions and the potential for adverse effects.
• Combination therapy may be more effective for achieving blood pressure control, especially in patients with stage 2 hypertension.
• The patient's history of stroke and hypertension suggests the need for careful management of their blood pressure to prevent further cardiovascular events.
• Given the patient's situation, it might be beneficial to consider a combination therapy approach, as suggested by studies 3 and 6, and to weigh the benefits and risks of ACE inhibitors versus ARBs, as discussed in studies 4 and 5.