What admission orders should be placed for a 60‑year‑old male with hypertension and atherosclerotic cardiovascular disease?

Hospital Admission Orders for 60-Year-Old with Hypertensive Atherosclerotic Cardiovascular Disease

Admit this patient to a telemetry bed with continuous cardiac monitoring and initiate aggressive secondary prevention therapy targeting systolic blood pressure 120-130 mmHg, LDL-C <55 mg/dL, and antiplatelet therapy. 1, 2

Admission Status and Monitoring

• Admit to: Telemetry unit with continuous cardiac monitoring 2
• Vital signs: Every 4 hours including orthostatic blood pressures 1
• Telemetry monitoring: Continuous for arrhythmia detection 2
• Daily weights: To monitor volume status 2

Diagnostic Workup

Immediate Laboratory Studies

• Complete metabolic panel including estimated GFR to assess renal function and guide medication dosing 1, 2
• Lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) to guide statin intensity 2, 3
• Hemoglobin A1c to screen for diabetes (present in 32-36% of older ASCVD patients) 1
• High-sensitivity troponin and NT-proBNP for risk stratification (elevated biomarkers predict mortality independent of blood pressure) 1
• Complete blood count to assess for anemia before antiplatelet therapy 2
• Thyroid-stimulating hormone to exclude secondary hypertension 1

Cardiovascular Assessment

• 12-lead ECG to evaluate for left ventricular hypertrophy, prior infarction, and conduction abnormalities 1, 2
• Transthoracic echocardiogram to assess left ventricular systolic function, wall motion abnormalities, and hypertension-mediated organ damage 1
• Ankle-brachial index (ABI) given 79% of older ASCVD patients have coexistent peripheral arterial disease 1

Risk Stratification Imaging

• Stress imaging (adenosine or dipyridamole myocardial perfusion SPECT preferred over exercise ECG) to identify extent and severity of ischemia 2, 3
• Consider invasive coronary angiography with FFR/iwFR if stress imaging demonstrates high-risk features or symptoms are refractory to medical therapy 1, 2

Pharmacological Orders

Antiplatelet Therapy

• Aspirin 81-100 mg daily (mandatory for all ASCVD patients) 2, 4
• If aspirin intolerant: Clopidogrel 75 mg daily 2, 4

Lipid-Lowering Therapy

• High-intensity statin: Atorvastatin 80 mg daily OR Rosuvastatin 20 mg daily (mandatory for all ASCVD patients targeting LDL-C <55 mg/dL with ≥50% reduction from baseline) 2, 3, 4
• Ezetimibe 10 mg daily if LDL-C target not achieved with maximum tolerated statin dose 2, 3
• Consider PCSK9 inhibitor (evolocumab or alirocumab) if goals remain unmet on statin plus ezetimibe 3

Antihypertensive Therapy

• ACE inhibitor (e.g., lisinopril 10 mg daily, titrate to target) OR ARB if ACE inhibitor intolerant—recommended for all hypertensive ASCVD patients 1, 4
• Beta-blocker (e.g., metoprolol succinate 25-50 mg daily)—first-line for hypertensive patients with CAD, particularly if recent MI or symptomatic angina 1, 4, 5
• Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) if additional BP control needed or for angina management 1
• Target systolic BP 120-130 mmHg (NOT 130-140 mmHg given age 60 years, which is <65 years) 1
• Avoid diastolic BP <60 mmHg due to J-curve phenomenon compromising coronary perfusion during diastole 5

Diabetes Management (if present)

• SGLT2 inhibitor (empagliflozin 10 mg daily, canagliflozin 100 mg daily, OR dapagliflozin 10 mg daily) for cardiovascular event reduction 2
• GLP-1 receptor agonist (liraglutide OR semaglutide) for additional cardiovascular benefit 2

Anti-Anginal Therapy (if symptomatic)

• Sublingual nitroglycerin 0.4 mg PRN for acute angina (no interaction concerns) 4
• Beta-blocker as above serves dual purpose for BP and angina control 4

Activity and Diet Orders

• Cardiac diet: Mediterranean or DASH pattern, sodium restriction <2 grams daily 1, 3
• Activity: Bedrest with bathroom privileges initially, advance as tolerated based on stress test results 2
• Physical therapy consult for supervised exercise program planning (150-300 minutes moderate-intensity aerobic exercise weekly post-discharge) 3, 4

Consultations

• Cardiology consult for risk stratification, stress imaging interpretation, and consideration of invasive angiography if high-risk features present 1, 2
• Nutrition consult for dietary counseling on Mediterranean/DASH diet 3
• Smoking cessation program if current or recent smoker (20-30% prevalence in older ASCVD patients) 1

Nursing Orders

• Strict intake and output monitoring 2
• Fall precautions given antihypertensive therapy and orthostatic hypotension risk 1
• Patient education on disease process, risk factors, medication adherence, and warning signs of acute coronary syndrome 2

Follow-Up Planning

• Reassessment at 2-4 weeks post-discharge to evaluate medication tolerance, adherence, lipid panel response, and blood pressure control 2, 3
• Annual influenza vaccination (improves outcomes independent of pharmacotherapy) 3

Critical Pitfalls to Avoid

• Do NOT lower diastolic BP below 60 mmHg—this compromises coronary perfusion during diastole, especially with left ventricular hypertrophy and epicardial stenoses 5
• Do NOT use beta-blockers as sole first-line therapy without ACE inhibitor/ARB—RAS blockade is mandatory for event prevention 1
• Do NOT delay high-intensity statin initiation—this is non-negotiable regardless of baseline LDL-C level 2, 3, 4
• Do NOT perform coronary CTA as routine follow-up in established CAD—use stress imaging for ischemia assessment 1, 2
• Do NOT ignore coexistent peripheral arterial disease—perform ABI testing given 79% prevalence in this population 1