A 54-year-old woman comes to the office due to lower extremity swelling and discomfort over the past week. The patient says that she can no longer fit into her shoes. Otherwise, she feels fine and has no orthopnea, dyspnea on exertion, or chest pain. She was recently diagnosed with essential hypertension (systolic blood pressure 165-170 mm Hg and diastolic blood pressure 95-100 mm Hg) and was started on amlodipine. Complete blood count and chemistry panel were normal at that time.
The patient's current blood pressure is 156/95 mm Hg, pulse is 84/min, and respirations are 14/min. Pulse oximetry is 98% on room air. Her BMI is 28 kg/m². Jugular venous pressure is estimated at 8 cm H₂O. Lungs are clear to auscultation. There are no murmurs or additional heart sounds. The liver span is 10 cm and the spleen is not palpable. There is 2+ symmetric pitting edema involving her lower extremities.
Laboratory results are as follows:

Which of the following therapies, if it had been initiated with amlodipine, could have most likely prevented this patient's current condition?

Question

A 54-year-old woman comes to the office due to lower extremity swelling and discomfort over the past week. The patient says that she can no longer fit into her shoes. Otherwise, she feels fine and has no orthopnea, dyspnea on exertion, or chest pain. She was recently diagnosed with essential hypertension (systolic blood pressure 165-170 mm Hg and diastolic blood pressure 95-100 mm Hg) and was started on amlodipine. Complete blood count and chemistry panel were normal at that time.
The patient's current blood pressure is 156/95 mm Hg, pulse is 84/min, and respirations are 14/min. Pulse oximetry is 98% on room air. Her BMI is 28 kg/m². Jugular venous pressure is estimated at 8 cm H₂O. Lungs are clear to auscultation. There are no murmurs or additional heart sounds. The liver span is 10 cm and the spleen is not palpable. There is 2+ symmetric pitting edema involving her lower extremities.
Laboratory results are as follows:

Which of the following therapies, if it had been initiated with amlodipine, could have most likely prevented this patient's current condition?

Quizplus · Accepted Answer

Peripheral edema is a common, dose-dependent adverse effect of dihydropyridine calcium channel blockers (CCBs) and is seen in approximately 5%-10% of patients. It is thought to result from preferential arterial dilation, which increases the pressure gradient between the capillaries and interstitium, leading to extravasation of intravascular fluid. Combining renin-angiotensin system blockers with CCBs has been shown to reduce the risk of peripheral edema by promoting venule dilation and therefore decreasing the pressure gradient between the capillaries and interstitium. In addition, the ACCOMPLISH trial showed that dual therapy with an ACE inhibitor and a CCB was superior to ACE inhibitor plus thiazide diuretic in reducing cardiovascular events. As a result, the combination of an ACE inhibitor and a CCB is advocated for patients in whom the need for dual therapy is likely. (Choices B and C) Digoxin is used as an adjunctive therapy in heart failure patients with systolic dysfunction who continue to have symptoms despite medical therapy with an ACE inhibitor, beta blocker, aldosterone antagonist, and diuretics. Neither beta blockers nor digoxin would help this patient's peripheral edema as it is not due to heart failure (absence of pulmonary edema and jugular venous distension). (Choice D) Hydralazine is a direct arteriolar vasodilator and may further worsen this patient's CCB-induced peripheral edema. (Choice E) CCB-associated peripheral edema is not due to salt and water retention and responds poorly to diuretic therapy. In fact, CCBs have been shown to be natriuretic. Educational objective: ACE inhibitors can reduce the peripheral edema induced by calcium channel blockers (CCBs). CCB-associated peripheral edema responds poorly to diuretics as it is not due to salt and water retention. __________ References: Effect of renin-angiotensin system blockade on calcium channel blocker-associated peripheral edema. (http://www.ncbi.nlm.nih.gov/pubmed/21295192) Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients (http://www.ncbi.nlm.nih.gov/pubmed/19052124)

A 54-Year-Old Woman Comes to the Office Due to Lower