Pharmacology
Hypertension
Case Study
Patient Profile
Name: Mrs. Baltimore
Age: 54 years old
Gender: female
Current Medications
None
History of Present Illness
Mrs. Baltimore is a 54-year-old African American woman with a history of well-controlled type 2 diabetes mellitus. She is new to your practice. Her last HgA1C was 6.8. She meets the diagnostic criteria for essential hypertension stage two but she is not currently on any anti-hypertensive medications. Blood pressure log and review of previous records indicate SBP range 148-170 and DBP 88-100. She currently does not have any peripheral edema. Patient has a remote history of hepatitis B infection with treatment with hepatitis B vaccine series and hepatitis B immunoglobulin at the time of diagnosis. As far as she knows, her liver function is within normal limits. She has a history of stage 3a chronic kidney disease with the last eGFR documented two months ago as 45. She has otherwise been healthy and all routine immunizations and cancer screenings are up to date.
Relevant Assessment
Vital signs stable: Blood pressure: 150/96 mm Hg, heart rate: 68 bpm, BMI within normal range.
Cardiac: Regular rate and rhythm, S1, S2. No S3, S4, or edema.
No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.
Note: This situation is going to require more than one therapeutic agent; think carefully about the characteristics of this patient and what compelling conditions exist to guide agent selection. It is possible to use a single pill combination, referred to as SPC.
Differentials
Essential hypertension, renal artery stenosis, chronic kidney disease, hyperaldosteronism, obstructive sleep apnea, coarctation of the aorta
Diagnosis
Essential hypertension
Diagnostic Testing
CBCdiff (neutropenia), CMP (electrolyte imbalance, liver and renal function) (all resulted prior to and within normal limits, except confirmed stage 3a chronic kidney disease)
Referrals
None at this time
Patient/Provider Collaborative Goals
Mrs. Baltimore will achieve a blood pressure goal of less than 130 systolic and less than 80 diastolic by time of planned follow-up.
Therapeutic Interventions
- Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
Answer:
One option is amlodipine/benazepril 2.5 mg/10 mg tablet daily for four weeks.
- Drug Mechanism of Action:
Answer:
Amlodipine is a calcium channel blocker with the following mechanism of action: Inhibition of calcium from entering voltage sensitive areas of vascular smooth muscle and myocardial muscle during depolarization leading to relaxation of coronary vasculature and coronary vasodilation. This results in increased oxygen delivery to myocardium, peripheral vascular resistance, and blood pressure decrease.
Benazipril is an angiotensin converting enzyme inhibitor (ACEI) with the following mechanism of action: It inhibits the conversion of angiotensin I to angiotensin II. Angiotensin II is a powerful vasoconstrictor, so by preventing this conversion, blood pressure decreases. The decreased angiotensin II increases plasma renin and increases aldosterone secretion.
- Contraindications if applicable:
Answer:
Amlodipine: Hypersensitivity to the drug or components of the drug.
Benazapril: Hypersensitivity to the drug or components of the drug or other any other ACEI, any history of angioedema, a diabetic patient who also uses aliskiren, and concurrent neprilysin inhibitor (example sacubitril) use or having stopped neprilysin inhibitor less than 36 hours prior.
- Drug Mechanism of Action:
- Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
Answer:
Specific Instructions: The nurse practitioner should advise patients that amlodipine and benazepril are prescribed to help lower their blood pressure. Advise patients to inform all healthcare providers that they take this medication and all others, including over-the-counter medications and herbal supplements. Patients should avoid drinking alcohol and engaging in activities that require cognitive alertness until they know how the medication affects them. Advise patients to change positions slowly if sitting or lying down and to be careful going up and down stairs as these position changes may lead them to feel dizzy. Avoid the use of cough or cold medications, diet pills, stimulants, non-steroidal anti-inflammatory drugs like ibuprofen or naproxen and some natural products or aids. The rationale for avoiding these agents is that some of them can raise blood pressure.
Advise the patient that if they experience swelling of the face, mouth, or throat that they should call 911 for immediate medical attention.
- Therapeutic Monitoring: Patients can be asked to keep a daily log of their blood pressure before and about an hour after taking the medication to bring to their followup visit. The NP should assess heart rate and blood pressure at baseline and in four weeks, then every three months thereafter. Due to the ACEI component of the prescribed medication, benazepril, the NP should also monitor blood urea nitrogen, creatinine, and electrolytes, particularly potassium. This can be accomplished with a complete metabolic profile (CMP). The NP should also calculate atherosclerotic cardiovascular disease risk score (ASCVD score) at baseline and annually or with changes in condition.
- Adverse Effects: Although rare, new or worsening chest pain can happen with this medication. Heart attacks have also occurred particularly in patients who have diseased heart vessels. Advise patients to call 911 with any chest pain.
- Serious Adverse Effects:
- Peripheral Edema [amlodipine (Norvasc)]: Significant swelling of the lower legs, ankles, and feet may occur. Risk factors include higher doses, longer duration of therapy, and female gender. Patients may not be able to tolerate this edema, and it may require intervention such as adding a diuretic or changing the antihypertensive medication.
- Acute Kidney Injury [benazipril (Lotensin)]: Typically, there is an increase in creatinine, then the level stabilizes within 30% of the patient’s baseline. If the level of creatinine remains greater than 30% above baseline, closer monitoring is warranted and change in antihypertensive medication may be warranted.
- Angioedema [benazipril (Lotensin)]: Swelling of the face, mouth, lips, and tongue which can lead to life threatening airway obstruction and may occur as an adverse effect of angiotensin converting enzyme inhibitor therapy. Immediate medical attention is required to monitor the patient’s airway.
- Dry Hacking Cough [benazipril (Lotensin)]: This effect occurs more commonly in female patients. If a dry hacking cough becomes evident, a change in antihypertensive medication class will resolve the problem.
- Hyperkalemia [benazipril (Lotensin)]: Potassium should be monitored particularly in patients with conditions that also may lead to hyperkalemia, such as diabetes mellitus, heart failure, and chronic kidney disease. Use caution when considering the following medications as they also lead to hyperkalemia: Angiotensin receptor blockers, spironolactone, nonsteroidal anti-inflammatory drugs, beta blockers, heparin, tacrolimus, and cyclosporine. Additionally, a common antibiotic sulfamethoxazole/trimethoprim can elevate potassium levels and should not be combined with other medications that can increase potassium levels.
- Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
Answer:
Follow-up office visit in four weeks.
Review Questions
Click the arrow to expand the section and view the correct answers.
- Which of the following drug classes are prescribed for the compelling condition heart failure with reduced ejection fraction (Select all that apply):
- Angiotensin converting enzyme inhibitor
- Angiotensin receptor blocker
- Alpha 2 agonist
- Aldosterone antagonist
- Calcium channel blocker
- Beta blocker
- Diuretic
- Renin inhibitor
Answer:
A. Angiotensin converting enzyme inhibitor; B) Angiotensin receptor blocker; D) Aldosterone antagonist; F) Beta blocker; G) Diuretic
Feedback: Angiotensin converting enzyme inhibitor, angiotensin receptor blocker, aldosterone antagonist, beta blocker, and diuretic are classes of medications to use when the patient has the compelling condition of heart failure with reduced ejection fracture. These agents decrease fluid volume and/or dilate blood vessels, lowering blood pressure and thereby decreasing the workload on the heart while pumping blood. Allowing the heart to pump more effectively decreases fluid backup in the lungs and third spacing of fluid (fluid buildup outside the vascular system in tissues).
- Mrs. Baltimore is newly diagnosed with hypertension. She asks how taking an angiotensin converting enzyme inhibitor (ACEI) will help lower her blood pressure. Your best response based upon your knowledge of mechanism of action is:
- ACEI promotes angiotensin I to angiotensin II, the latter of which constricts blood vessels and makes the kidneys retain sodium and water; these mechanisms lower blood pressure.
- ACEI prevents angiotensin I to angiotensin II, the latter of which constricts blood vessels and makes the kidneys retain sodium and water; these mechanisms lower blood pressure.
- ACEI prevents angiotensin II to angiotensin I, the latter of which constricts blood vessels and makes the kidneys retain sodium and water; these mechanisms lower blood pressure.
- ACEI promotes angiotensin II to angiotensin I, the latter of which constricts blood vessels and makes the kidneys retain sodium and water; these mechanisms lower blood pressure.
Answer:
B. ACEI prevents angiotensin I to angiotensin II, the latter of which constricts blood vessels and makes the kidneys retain sodium and water; these mechanisms lower blood pressure.
Feedback: ACEI prevents angiotensin II to angiotensin I which constricts blood vessels and makes the kidneys retain sodium and water.
- Mrs. Baltimore is newly diagnosed with hypertension. She also has diabetes and chronic kidney disease. She asks how taking an angiotensin converting enzyme inhibitor (ACEI) will protect her kidneys Your best response based upon your knowledge of mechanism of action is:
- Lowering blood pressure increases the pressure within the kidneys which protects their structural integrity and decreases loss of protein in the urine.
- Lowering blood pressure decreases the pressure within the kidneys which protects their structural integrity and increases loss of protein in the urine.
- Increasing blood pressure decreases the pressure within the kidneys which protects their structural integrity and decreases loss of protein in the urine.
- Lowering blood pressure decreases the pressure within the kidneys which protects their structural integrity and decreases loss of protein in the urine.
Answer:
D. Lowering blood pressure decreases the pressure within the kidneys which protects their structural integrity and decreases loss of protein in the urine.
Feedback: Angiotensin converting enzyme inhibitor drugs lower blood pressure which decreases the pressure within the kidneys, protecting their structural integrity and decreasing loss of protein in the urine which is a sign of kidney damage. Additionally, by blocking kidney damaging hormones within the renin-angiotensin system, ACEI are renal protective.
- Mr. Smith recently had lab work. His electrolytes, renal, and hepatic function are all within normal limits. When selecting treatment to treat his hypertension, what is the best class of medication to use if Mr. Smith has peripheral edema?
- Calcium channel blocker
- Angiotensin converting enzyme inhibitor
- Diuretic
- Beta blocker
Answer:
C. Diuretic
Feedback: Using diuretics to treat hypertension in a patient with peripheral edema will help alleviate excess fluid from the body and decrease the edema. If a patient has challenges with hypokalemia, it is safer to select a potassium sparing diuretic. (Examples: sodium channel blockers: amiloride (Midamor) and triamterene (Dyrenium); mineralocorticoid receptor antagonists: eplerenone (Inspra) and spironolactone (Aldactone)). Also, be aware that some classes of anti-hypertensive medications can cause peripheral edema; this can be particularly problematic with calcium channel blockers.
- Mrs. Ackley is a 66-year-old female with osteoporosis. Which medication is the best choice when you diagnosed her with stage 1 hypertension today?
- Hydrochlorothiazide (HCTZ)
- Lisinopril
- Metoprolol
- Amlodipine
Answer:
A. Hydrochlorothiazide (HCTZ)
Feedback: A desired effect of HCTZ is slowing calcium loss from bones and stimulation of bone resorbing cells called osteoblasts.
- What is a reversible adverse effect of the potassium sparing diuretic spironolactone (aldosterone antagonists)?
- Breast tissue loss
- Acne exacerbation
- Hypokalemia
- Gynecomastia
Answer:
D. Gynecomastia
Feedback: Gynecomastia is a generally reversible adverse effect of the aldosterone antagonist potassium sparing diuretic spironolactone. Hyperkalemia, not hypokalemia, is an adverse effect of spironolactone because it is an aldosterone antagonist and is a potassium sparing diuretic. Spironolactone does not exacerbate acne, but rather can be used to treat acne.
- Mr. Baker is a 57-year-old male with a history of essential hypertension, obesity, and hypercholesterolemia. He is on your schedule for a sick visit today for a dry, non-productive cough. He was seen about two months ago for this cough in urgent care and again one month ago due to non-resolution of the cough. Over the two-month period, he has been prescribed and has taken two antibiotics (azithromycin [Zithromax] and amoxicillin), an albuterol inhaler, and a prednisone burst for five days. Which of the following medications do you suspect has caused his dry non-productive non-resolving cough?
- Verapamil
- Rosuvastatin
- Lisinopril
- Hydrochlorothiazide
Answer:
C. Lisinopril
Feedback: Lisinopril and other angiotensin converting enzyme inhibitors and, to a lesser frequency, angiotensin receptor blockers (ARBs) can lead to a dry non-productive cough which can be resolved by stopping the agent and using a different class of antihypertensive. This cough is due to a buildup of bradykinin and occurs more frequently in women and in up to 20% of patients who use ACEIs. Other adverse and serious potential effects of ACEIs and ARBs are angioedema and hyperkalemia. Educate your patients about the potential for facial swelling and that they should go to the emergency department should this occur. Angioedema is rare but life threatening and can occur even after the patient has been using the medication for a long time. Do not combine ACEIs or ARBs with potassium sparing diuretics due to increased risk of hyperkalemia. Use caution if a patient has renal artery stenosis; ACEIs or ARBs can lead to hypoperfusion of the kidneys, leading to acute kidney injury. ACEI and ARBs are contraindicated in bilateral renal artery stenosis.
- Which patient is the best candidate for having their hypertension treated with an alpha1-blocker/antagonist (such as terazosin [Hytrin], doxazosin [Cardura], and tamsulosin [Flomax])?
- A 50-year-old female with hypercholesterolemia
- A 50-year-old female with history of diabetes
- A 70-year-old male with obesity
- A 70-year-old male with benign prostatic hypertrophy
Answer:
D. A 70-year-old male with benign prostatic hypertrophy
Feedback: Though alpha1-blocker/antagonists (terazosin [Hytrin], doxazosin [Cardura], and tamsulosin [Flomax]) are not considered first-line therapy for the management of hypertension, it is reasonable to select this class of medication as part or all the first-line treatments for hypertension in a patient with benign prostatic hypertrophy as both conditions would be treated with this class of medications.
References
Condina Leik, M. T. (2025). Cardiovascular system review. In FNP Certification Intensive Review (pp. 161–194). Springer Publishing.
Desbiens, L. C., Khelifi, N., Wang, Y. P., Lavigne, F., Beaulieu, V., Sidibe, A., & Mac-Way, F. (2022). Thiazide diuretics and fracture risk: A systematic review and meta-analysis of randomized clinical trials. Journal of Bone and Mineral Research Plus 6(11), 1–13. doi.org/10.1002/jbm4.10683
Rosenthal, L. D., & Burchum, J. R. (2026). Calcium channel blockers. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 304–308). Elsevier.
Rosenthal, L. D., & Burchum, J. R. (2026). Diuretics. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 286–292). Elsevier.
Rosenthal, L. D., & Burchum, J. R. (2026). Drugs acting on the renin-angiotensin-aldosterone system. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 293–303). Elsevier.
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