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1
Question:

A 70-year-old man comes to the office for a follow-up for gout.  It has been well controlled, with no joint pain since he started taking allopurinol 6 months ago.  The patient has had no chest pain, trouble breathing, headaches, or lightheadedness.  He does not use tobacco, alcohol, or illicit drugs.  The patient's blood pressure was 145/90 mm Hg and 150/95 mm Hg at his 2 previous visits.  Today, his blood pressure is 148/92 mm Hg on the left arm and 144/90 mm Hg on the right arm.  Physical examination is normal.  Complete blood cell count, serum creatinine, serum electrolytes, TSH, uric acid, and urinalysis results are normal.  ECG indicates left ventricular hypertrophy.  Which of the following is the best next step in managing this patient?

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Explanation:

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Choice of antihypertensive drug
for comorbid conditions

Coronary
atherosclerosis

  • Angina pectoris: β-blocker, CCB
  • Post–myocardial infarction: ACE inhibitor or ARB, β-blocker

Heart failure
with reduced
ejection fraction

  • ACE inhibitor or ARB, β-blocker, diuretic, aldosterone antagonist

Atrial fibrillation
or flutter

  • β-Blocker, nondihydropyridine CCB

Chronic kidney
disease

  • ACE inhibitor or ARB

Gout

  • Losartan, other ARB, CCB (avoid diuretics)

Osteoporosis

  • Thiazide diuretic

Migraine

  • β-Blocker, CCB

ARB = angiotensin II receptor blocker; CCB = calcium channel blocker.

This patient has newly diagnosed hypertension, confirmed by measurements on 3 different office visits.  His initial workup shows evidence of end-organ injury (ie, left ventricular hypertrophy [LVH]), so antihypertensive treatment must be started without delay (Choice C).

First-line antihypertensive agents that can lower blood pressure and minimize LVH include angiotensin II receptor blockers (ARBs), ACE inhibitors, calcium channel blockers, and thiazide diuretics.  However, comorbid gout in this patient makes thiazide diuretics (Choice D) a poor choice because they can raise uric acid levels and increase the risk of gout attack.  In contrast, the ARB losartan has a mild uricosuric effect, which decreases the risk of gout attack.  In addition, ARBs provide the greatest reduction in LVH of all first-line antihypertensive agents.  Other antihypertensive options for patients with gout include other ARBs, ACE inhibitors, and calcium channel blockers.

(Choice A)  Discontinuing allopurinol would not decrease the patient's blood pressure or address LVH, putting him at increased risk for stroke, myocardial infarction, and additional hypertensive damage.  Without allopurinol, the patient's uric acid level would increase, causing more frequent gout attacks.

(Choice B)  Exercise stress testing is used to evaluate cardiac ischemia; this patient has no evidence of ischemia (eg, chest pain, dyspnea, ST-segment depression).  Echocardiography should be considered to further assess LVH, but obtaining this test should not delay initiation of blood pressure medication.

Educational objective:
Losartan is an angiotensin II receptor blocker (ARB) that has a mild uricosuric effect and is the preferred first-line antihypertensive drug for patients with gout.  Other options include other ARBs, ACE inhibitors, and calcium channel blockers.  Thiazide diuretics can raise circulating uric acid levels and should be avoided.