Should enalaprilat be administered to a post-operative patient with hypertension and tachycardia, or an alternative antihypertensive medication be ordered?

From the Guidelines

Given the patient's elevated blood pressure (179/80) and tachycardia (HR 94-100s), I would recommend administering the ordered PRN enalaprilat rather than hydralazine, as enalaprilat can effectively lower blood pressure without significantly increasing heart rate, unlike hydralazine which often causes reflex tachycardia 1. For this post-surgical spine patient with existing tachycardia, avoiding further heart rate elevation is important.

The patient's history of hypertension, diabetes, and recent spinal surgery makes blood pressure control particularly important to reduce risk of surgical site bleeding and cardiovascular complications. According to 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, the therapeutic goal is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment 1.

Some key points to consider in this patient's management include:

• The presence of comorbidities, such as hypertension, diabetes, and neuropathy, which can impact the choice of antihypertensive medication
• The need to avoid medications that may cause reflex tachycardia, such as hydralazine, in patients with existing tachycardia
• The importance of closely monitoring the patient's response to enalaprilat, including blood pressure and heart rate, and reassessing in 15-30 minutes after administration to determine if additional intervention is needed
• The potential need to add a beta-blocker, such as metoprolol, if the enalaprilat does not adequately control the blood pressure, to address both the hypertension and tachycardia simultaneously.

It is also important to note that there is no RCT evidence comparing different strategies to reduce BP, except in patients with ICH, and that the choice of antihypertensive medication should be individualized based on the patient's specific clinical characteristics and comorbidities 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION FOR INTRAVENOUS ADMINISTRATION ONLY The dose in hypertension is 1. 25 mg every six hours administered intravenously over a five minute period. Patients On Diuretic Therapy For patients on diuretic therapy the recommended starting dose for hypertension is 0. 625 mg administered intravenously over a five minute period;

The patient has a history of hypertension (HTN) and is currently experiencing high blood pressure (179/80) with a heart rate of 94. Given that the patient is tachycardic, it is essential to consider the potential effects of administering enalaprilat.

• The recommended dose for patients with hypertension is 1.25 mg every six hours.
• However, since the patient is on diuretic therapy, the recommended starting dose is 0.625 mg. Considering the patient's tachycardia, it may be more appropriate to consider alternative options for managing the patient's blood pressure, rather than administering the ordered PRN enalaprilat. It is crucial to weigh the potential benefits and risks of administering enalaprilat in this scenario, taking into account the patient's renal function and volume status. Given the information provided, it is not possible to make a definitive recommendation without further evaluation of the patient's condition. 2

From the Research

Patient's Condition

The patient is status post anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF), a two-stage procedure, with a history of hypertension (HTN), diabetes mellitus (DM), neuropathy, spinal stenosis, and degenerative disc disease. The patient's latest blood pressure reading is 179/80 mmHg, with a heart rate (HR) of 94 beats per minute (bpm), which is consistently within the 90s to 100s.

Medication Considerations

The patient has been prescribed hydralazine, but due to the patient's tachycardia, the consideration is to administer the ordered PRN enalaprilat or to order another blood pressure medication instead.

• The patient's tachycardia is a significant concern, as studies have shown that elevated heart rate is a strong predictor of cardiovascular risk 3, 4, 5.
• Beta-blockers are often used to manage tachycardia and hypertension, and studies have demonstrated their effectiveness in reducing cardiovascular risk 4, 6, 5.
• However, the patient's current heart rate and blood pressure readings suggest that alternative medications or adjustments to the current medication regimen may be necessary.

Treatment Options

• Administering enalaprilat, an ACE inhibitor, may help to lower the patient's blood pressure, but its effect on heart rate is unclear.
• Considering alternative beta-blockers, such as carvedilol or metoprolol, which have been shown to be effective in reducing heart rate and cardiovascular risk 4, 6.
• Non-pharmacological approaches, such as lifestyle changes, may also be beneficial in managing the patient's tachycardia and hypertension 5.

Key Considerations

• The patient's tachycardia is a significant concern and should be addressed promptly.
• The choice of medication should be based on the patient's individual needs and medical history.
• Close monitoring of the patient's heart rate and blood pressure is essential to ensure effective management of their condition.