Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – B3

ANSWER — 

Correct.

Since the goal of therapy is the elimination of symptoms, no further pharmacologic intervention is indicated. Elimination of the orthostatic fall in blood pressure is not usually possible or necessary in a patient with autonomic orthostatic hypotension. For each patient, there appears to be an upright systolic blood pressure above which symptoms do not occur.

Two weeks later, the visiting nurse calls to report the patient's blood pressure values at home. The supine blood pressure readings with the head of the bed elevated by 4 inches (10 cm) are in the range of 184 to 197/71 to 78 mmHg. The upright blood pressure readings are in the range of 128 to 137/66 to 73 mmHg. The nurse is concerned about the long-term consequences of supine systolic hypertension.

What do you recommend?

●No further intervention. You have achieved the goal of elimination of the patient's orthostatic symptoms and accept supine systolic hypertension in this patient. You do not wish to risk recurrent orthostatic symptoms by adding an additional antihypertensive agent. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – C1".)

●Change the time of administration of lisinopril 10 mg from morning to bedtime. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – C2".)

●Stop lisinopril and add atenolol 25 mg every morning. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – C3".)