How should I evaluate and manage a 31‑year‑old woman with a history of preeclampsia and intravenous drug use who presents with intermittent palpitations, lightheadedness, a ten‑month cough, and afternoon hypertension while taking losartan 50 mg, with a normal sinus rhythm on electrocardiogram?

Evaluation and Management of a 31-Year-Old Woman with History of Preeclampsia, IV Drug Use, Palpitations, Chronic Cough, and Afternoon Hypertension

Immediate Medication Change Required

Losartan must be discontinued immediately and replaced with nifedipine extended-release or labetalol, as angiotensin receptor blockers are absolutely contraindicated in women of childbearing age who may become pregnant due to severe fetotoxicity. 1, 2

• ARBs cause renal dysgenesis, oligohydramnios, and severe fetal complications if pregnancy occurs 3, 2
• A documented case report showed oligohydramnios resolved within 8 days after switching from losartan to nifedipine in a pregnant woman 3
• Switch to extended-release nifedipine 30-60 mg once daily OR labetalol 100 mg twice daily, titrating as needed 2, 1

Cardiovascular Evaluation for Palpitations and Lightheadedness

Order a 24-hour Holter monitor and transthoracic echocardiogram to evaluate for arrhythmias and structural heart disease, particularly given her IV drug use history. 1

Specific Concerns Related to IV Drug Use:

• Screen for infective endocarditis with echocardiography (vegetations, valve dysfunction) 1
• Assess for cardiomyopathy or left ventricular dysfunction 1
• Evaluate for pulmonary hypertension, which can cause palpitations and lightheadedness 1
• Check troponin if any chest pain accompanies palpitations 1

Additional Cardiac Workup:

• ECG already shows normal sinus rhythm, but capture rhythm during symptomatic episodes with Holter monitoring 1
• If palpitations correlate with hypertensive episodes, consider pheochromocytoma screening (24-hour urine metanephrines) 1

Evaluation of 10-Month Cough

Obtain chest X-ray and consider CT chest to evaluate for infectious, inflammatory, or structural pulmonary pathology related to IV drug use. 1

IV Drug Use-Related Pulmonary Complications:

• Screen for tuberculosis with chest X-ray and tuberculin skin test or interferon-gamma release assay 1
• Evaluate for septic pulmonary emboli (multiple peripheral nodular infiltrates on imaging) 1
• Consider HIV testing, as chronic cough may indicate opportunistic infections 1
• Assess for pulmonary hypertension with echocardiography (can cause chronic cough) 1

Alternative Causes:

• ACE inhibitor-induced cough is not applicable since she's on an ARB 2
• Consider asthma or reactive airway disease (obtain pulmonary function tests if chest X-ray normal) 1
• Evaluate for heart failure with BNP and echocardiography (chronic cough can indicate pulmonary congestion) 1

Hypertension Management Strategy

Target blood pressure should be <140/90 mmHg with extended-release nifedipine as first-line therapy after discontinuing losartan. 1, 2

Dosing Algorithm:

• Start nifedipine extended-release 30 mg once daily 2
• Titrate by 30 mg increments every 1-2 weeks up to maximum 120 mg daily 2
• If blood pressure remains uncontrolled on nifedipine 120 mg daily, add labetalol 100 mg twice daily, titrating up to 2400 mg/day in divided doses 2
• Alternative: Use labetalol monotherapy if nifedipine causes headache, tachycardia, or edema 2

Monitoring Requirements:

• Home blood pressure monitoring twice daily to capture afternoon hypertension pattern 2
• If blood pressure reaches ≥160/110 mmHg, treat urgently within 60 minutes to prevent stroke 1, 4
• For acute severe hypertension: immediate-release nifedipine 10-20 mg orally, repeatable every 20-30 minutes (maximum 30 mg in first hour) 1, 2

Secondary Hypertension Workup

Given her young age, history of preeclampsia, and refractory afternoon hypertension, screen for secondary causes of hypertension. 1

Essential Laboratory Tests:

• Complete metabolic panel (creatinine, electrolytes, glucose) 1
• Urinalysis with protein-to-creatinine ratio (assess for renal disease post-preeclampsia) 1, 5
• Complete blood count, liver function tests 1
• Thyroid-stimulating hormone (hyperthyroidism can cause palpitations and hypertension) 1

Targeted Secondary Hypertension Screening:

• 24-hour urine metanephrines and catecholamines (pheochromocytoma can cause paroxysmal hypertension with palpitations) 1
• Morning plasma aldosterone-to-renin ratio if hypokalemia present (primary aldosteronism) 1
• Renal ultrasound with Doppler to evaluate for renal artery stenosis 1
• Consider renal function assessment given preeclampsia history (increased risk of chronic kidney disease) 5

Long-Term Cardiovascular Risk Management

Women with history of preeclampsia require lifelong cardiovascular surveillance due to significantly increased risk of chronic hypertension, stroke, and cardiovascular disease. 5, 2

• Annual blood pressure monitoring and cardiovascular risk assessment 5
• Aggressive lifestyle modification counseling (sodium restriction <2.4 g/day, weight management, exercise) 2
• Screen for diabetes mellitus (increased risk post-preeclampsia) 5
• Consider low-dose aspirin 81 mg daily for cardiovascular risk reduction if no contraindications 1

Critical Pitfalls to Avoid

• Never continue ARBs in women of childbearing potential without reliable contraception – fetotoxicity risk is severe 1, 2, 3
• Do not use immediate-release nifedipine for chronic management – risk of uncontrolled hypotension and myocardial infarction 2
• Avoid concurrent nifedipine with magnesium sulfate if acute severe hypertension develops – risk of precipitous hypotension 1, 2
• Do not dismiss palpitations in IV drug users – high risk of endocarditis and structural heart disease 1
• Do not attribute chronic cough to medication alone – investigate for serious pulmonary pathology given IV drug use history 1
• Avoid NSAIDs for pain management given hypertension and potential renal involvement 5

Contraception Counseling

Provide reliable contraception counseling immediately, as unplanned pregnancy on current losartan therapy would pose severe fetal risk. 2

• Discuss long-acting reversible contraception (IUD or implant) as most effective options 2
• If pregnancy desired in future, preconception counseling with medication optimization at least 3 months before conception 2
• Emphasize absolute need to discontinue ARB before any pregnancy attempt 2