What is the best course of action for a 49-year-old patient with a history of Hypertension (HTN) who suffered a stroke, has a 6-year history of daily alcohol consumption consistent with Alcohol Use Disorder (AUD), and is in need of antihypertensive medication refills and post-stroke follow-up testing?

From the Guidelines

I strongly recommend immediately restarting the patient's antihypertensive medications to manage their hypertension, especially given their recent stroke, as emphasized by the 2023 guidelines from the World Stroke Organization 1. The specific medication and dosage should match their previous prescription, with consideration for adding a second agent if blood pressure remains uncontrolled. The patient should schedule the missed cardiology follow-up testing as soon as possible, as this is critical for post-stroke care and secondary prevention. For the alcohol use disorder, I recommend starting hydroxyzine as requested for anxiety symptoms while continuing to encourage formal treatment. The patient should be prescribed 25-50mg of hydroxyzine to be taken as needed for anxiety, with clear instructions to avoid alcohol while taking this medication due to additive CNS depression effects. A comprehensive metabolic panel and complete blood count should be ordered today to assess liver function and other parameters that may be affected by chronic alcohol use. The patient should return for follow-up in 1-2 weeks to reassess blood pressure control and medication adherence. Controlling hypertension is particularly urgent in this case as it's a major risk factor for recurrent stroke, and the patient's alcohol use further complicates their cardiovascular risk profile. While respecting the patient's autonomy regarding alcohol treatment, providing resources for AA meetings and maintaining the recommendation for formal detoxification remains important for their long-term health, as supported by the American College of Emergency Physicians' recommendations for ED-based interventions for alcohol use disorder 1. Additionally, 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 suggests that restarting antihypertensive therapy to improve long-term BP control is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable 1.

Some key points to consider in the management of this patient include:

• The importance of blood pressure management in preventing recurrent stroke, as highlighted by the World Stroke Organization's 2023 guidelines 1
• The need for individualized approach to the selection of antihypertensive medications based on comorbidities, such as alcohol use disorder
• The potential benefits of ED-based interventions for alcohol use disorder, including brief interventions and referrals to outpatient treatment, as recommended by the American College of Emergency Physicians 1
• The importance of follow-up and monitoring to assess the effectiveness of treatment and make adjustments as needed.

From the FDA Drug Label

Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits

The patient is a 49-year-old with a history of hypertension who suffered a stroke. The use of lisinopril is indicated for the treatment of hypertension in adult patients to lower blood pressure, which in turn lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions 2.

• Key points:
  • Lisinopril is used to treat hypertension.
  • Lowering blood pressure reduces the risk of strokes and myocardial infarctions.
  • The patient has a history of hypertension and recently suffered a stroke.

Given the patient's history of hypertension and recent stroke, it is reasonable to continue lisinopril to manage their hypertension and reduce the risk of future cardiovascular events 2.

From the Research

Patient's Current Concerns

• The patient is a 49-year-old with a history of hypertension who suffered a stroke just before Thanksgiving.
• The patient has run out of their antihypertensive medications approximately four weeks ago and needs refills.
• The patient has not completed the recommended post-stroke follow-up testing with cardiology.
• The patient has a 6-year history of daily alcohol consumption consistent with alcohol use disorder.

Antihypertensive Medications and Depression

• There is evidence that certain antihypertensive medications can induce or worsen depression, including reserpine, alpha-methyldopa, and beta-blockers 3.
• Diuretics, calcium channel blockers, and angiotensin converting enzyme (ACE) inhibitors appear to have the lowest association with depression and are therefore the drugs of choice when depression is a risk 3.

Effects of Antihypertensive Drug Combinations on Blood Pressure

• Different combinations of antihypertensive therapy can be effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension 4.
• The study found that lisinopril, losartan, or valsartan alone or in combination with hydrochlorothiazide, with or without amlodipine, were equally effective and well-tolerated for reducing blood pressure and improving arterial stiffness.

Alcohol Use and Blood Pressure

• Alcohol use is associated with increased blood pressure among adults with hypertension, and this relationship is direct and not mediated by other health behaviors 5.
• Heavy binge drinking is a significant risk factor for stroke, and hypertensive patients should be warned about the risks of alcohol and urged to avoid binge drinking 6.

Initiating Antihypertensive Drug Treatment

• The evidence for initiating antihypertensive drug treatment at certain blood pressure levels is scanty, but current recommendations can be accepted as prudent statements 7.
• Lowering systolic blood pressure below 130 mmHg appears to be well-tolerated, but more solid evidence is needed to support current recommendations 7.