What is the appropriate management for a 47-year-old male patient with a history of epistaxis (nosebleeds) and headaches, who has a family history of hypertension (High Blood Pressure) and aneurysm, and a personal history of hypertension, nasal reconstruction after a motor vehicle accident (MVA), and adverse reactions to acetaminophen and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), currently not taking any medication, and now being started on lisinopril (10 mg) for hypertension (HTN) management?

From the Guidelines

I strongly recommend starting the 47-year-old male patient with nosebleeds, headaches, and a history of hypertension on lisinopril 10 mg daily, as it is a suitable alternative given his adverse reactions to acetaminophen and NSAIDs, and it effectively lowers blood pressure by preventing the conversion of angiotensin I to angiotensin II, thereby reducing vasoconstriction and sodium retention 1. The patient should monitor his blood pressure twice weekly for two weeks and follow up with a Chronic Disease Prevention (CDP) provider for ongoing hypertension management. This approach addresses his likely uncontrolled hypertension, which may be causing his current symptoms. Given the patient's family history of hypertension and aneurysm, it is crucial to manage his blood pressure effectively to reduce the risk of cardiovascular complications. The patient's history of adverse reactions to acetaminophen and NSAIDs has been noted, and lisinopril is a suitable alternative for managing his symptoms, as it does not interfere with blood pressure control like NSAIDs do 1. Regular blood pressure monitoring will help assess the medication's effectiveness and allow for dosage adjustments if needed. The referral to a CDP provider ensures comprehensive long-term management of his hypertension, which is essential for reducing the risk of myocardial infarction, stroke, end-stage renal disease, and death associated with uncontrolled hypertension 1. Key considerations in managing this patient's hypertension include:

• Accurate office blood pressure measurements
• Assessment for nonadherence to prescribed antihypertensive medications
• Obtaining home or ambulatory blood pressure readings to rule out the white coat effect
• Identifying and addressing contributing lifestyle factors
• Discontinuing or minimizing substances that interfere with antihypertensive therapy, such as nonsteroidal anti-inflammatory drugs, stimulants, and oral contraceptives
• Excluding secondary causes of hypertension 1.

From the FDA Drug Label

Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor In some cases, the angioedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery, and symptoms resolved after stopping the ACE inhibitor Monitor renal function periodically in patients treated with lisinopril. Lisinopril can cause symptomatic hypotension, sometimes complicated by oliguria, progressive azotemia, acute renal failure or death The patient has a history of nosebleeds and headaches, and a family history of high blood pressure and aneurysm. The patient is starting lisinopril for high blood pressure.

• The patient should be monitored for signs of angioedema, particularly given his history of nose reconstruction.
• The patient's renal function should be monitored periodically.
• The patient should be monitored for signs of hypotension, particularly given his history of headaches.
• The patient's potassium levels should be monitored periodically. Given the patient's history of adverse reactions to acetaminophen and NSAIDs, it is essential to monitor him closely for any potential reactions to lisinopril 2.

From the Research

Patient's Condition and Treatment

• The patient is a 47-year-old male with complaints of nosebleeds and headaches, and a history of high blood pressure.
• The patient's father had high blood pressure and died from an aneurysm, suggesting a possible genetic component to the patient's condition.
• The patient has a history of nose reconstruction due to an MVA 31 years ago.
• The patient is not currently taking any medication and reports adverse reactions to acetaminophen and NSAIDs.

Treatment Plan

• The patient will be started on lisinopril (10 mg) and will have BP checks twice a week for two weeks.
• The patient will be referred to the CDP provider for HTN.
• According to 3, lisinopril is an effective treatment for essential hypertension, and many patients achieve adequate blood pressure reduction with lisinopril alone.
• As stated in 4, lisinopril is also effective in lowering blood pressure in elderly patients with hypertension, with 68.2 to 89.1% of patients responding to treatment.

Considerations for Treatment

• The patient's adverse reactions to acetaminophen and NSAIDs should be taken into account when considering treatment options.
• As noted in 5, NSAIDs can increase blood pressure and interfere with antihypertensive medications, so alternative pain management options may be necessary.
• The timing of lisinopril administration may also be important, as shown in 6, where administration at 10:00 PM was found to be more effective in reducing blood pressure during the early morning hours when cardiovascular risk is higher.

Combination Therapy

• If the patient's blood pressure is not adequately controlled with lisinopril alone, combination therapy with other antihypertensive agents may be necessary.
• As recommended in 7, combination antihypertensive therapy can be an effective option for achieving adequate blood pressure control, and may include combinations of diuretics, beta blockers, ACE inhibitors, and calcium channel blockers.