What is the best course of action for a 49-year-old patient with a history of hypertension, who recently suffered a stroke, has not taken antihypertensive medications for approximately four weeks, and has a history of alcohol use disorder, presenting with a need for medication refills and laboratory tests?

From the Guidelines

The patient requires immediate attention for multiple health concerns, and I strongly recommend refilling their antihypertensive medications promptly, continuing their previous regimen, and scheduling urgent follow-up with cardiology for the missed post-stroke testing, as this is critical for secondary stroke prevention. Given their recent stroke and uncontrolled hypertension, it is essential to prioritize their cardiovascular health to reduce the risk of recurrent stroke. According to the 2023 systematic review and synthesis of global stroke guidelines 1, blood pressure management is crucial in patients with ischemic stroke or TIA, and antihypertensive treatment should be initiated as soon as possible after a stroke or TIA.

The patient's laboratory tests should include:

• Comprehensive metabolic panel
• Lipid profile
• HbA1c
• Liver function tests to assess overall health status and monitor for complications from both hypertension and alcohol use.

Regarding the alcohol use disorder, while the patient has contacts for rehabilitation, they should be strongly encouraged to seek formal detoxification in an emergency department setting due to the risks of withdrawal complications, especially given their daily drinking for six years. The combination of untreated hypertension and ongoing alcohol use significantly increases their stroke risk. As recommended in the 2023 systematic review and synthesis of global stroke guidelines 1, counseling for alcohol intake reduction is recommended for patients with ischemic stroke or TIA who drink > 2 alcoholic drinks daily for men or > 1 alcoholic drink daily for women.

A multidisciplinary approach involving primary care, cardiology, and addiction medicine would provide the most comprehensive care for this high-risk patient. The 2018 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 emphasizes the importance of blood pressure management in patients with a history of stroke, and the 2023 systematic review and synthesis of global stroke guidelines 1 provides recommendations for secondary prevention after stroke, including blood pressure management and lifestyle modifications.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient's Current Condition

The patient is a 49-year-old with a history of hypertension who suffered a stroke just before Thanksgiving. They have not taken their antihypertensive medications for approximately four weeks and have not completed the recommended post-stroke follow-up testing with cardiology.

Medication Refills and Labs

The patient presents today needing medication refills and labs. According to the study 2, initiation and optimization of oral antihypertensive therapy in indicated patients can be done by ED providers to enhance and expedite transition of care for patients and can ultimately aid in prevention of cardiovascular disease (CVD).

Antihypertensive Medication Options

The patient's medication options can be considered based on the studies:

• The combination of lisinopril and amlodipine is optimal and universal for effective treatment of patients with hypertension in combination with arteriosclerosis obliterans in all types of central hemodynamics 3.
• Lisinopril, losartan, or valsartan alone or in combination with hydrochlorothiazide, and with or without amlodipine, are equally effective and well-tolerated for the reduction of both systolic and diastolic blood pressure and improve arterial stiffness in patients with essential hypertension 4.
• Amlodipine and lisinopril in combination have a marked additional effect on blood pressure compared with either given as monotherapy, and their potentiation of action is long-acting 5.

Alcohol Use Disorder

The patient reports daily drinking for the last 6 years and has contact at Grace Manner to get back into rehab. Extensive education was given about ER for detox, and the patient verbalized understanding and will reach out to their contacts. The patient denies any need for getting into a treatment center and is aware of AA meetings. However, there is no direct evidence from the provided studies to address the patient's alcohol use disorder.

Post-Stroke Follow-up Testing

The patient has not completed the recommended post-stroke follow-up testing with cardiology. According to the study 6, controlling cardiovascular (CV) risk factors is paramount in reducing atherosclerotic events, and fixed-combination lisinopril-amlodipine plus rosuvastatin was well-tolerated and effective in patients with mild/moderate hypertension and hypercholesterolemia at high/very high CV risk.

Key Considerations

• The patient's blood pressure and cardiovascular risk factors should be closely monitored and managed.
• The patient's medication regimen should be optimized to achieve blood pressure targets and reduce cardiovascular risk.
• The patient's alcohol use disorder should be addressed, and they should be encouraged to seek treatment and support.
• The patient should be scheduled for follow-up testing with cardiology to assess their cardiovascular risk and develop a plan to reduce their risk of future cardiovascular events.