How meds affect blood pressure

Posted by Janis on June 17, 1999 at 15:51:34
My husband (61 years old, no smoke, no drink, no drugs, weight normal) has a history of stroke -- '91, small left side, '94 moderate left side, and April '99 moderate both frontal lobes (at which time, he also had a moderate MI).  He had a quad by-pass in Oct of '98 for five blockages of 80+ percent.  He also has two right-side carotid blockages of 70 and 80 percent, which are inoperable due to location.  He is home with me recuperating from the hospitalization in April and doing well except for his blood pressure.  His pressure tends to be higher at night and lower in the day time, so he has trouble sleeping at night and conks out all morning, early afternoon.  Of course, this plays havoc with our schedule and leaves me in the lurch as I'm not a good napper.  I've been trying to change this by rearranging when he gets his meds, which are all prescribed for once daily.
He's currently taking:  Isosorbide 60 mg; Atenolol 50 mg; Coumadin 2.5 mg (or slightly diff when indicated by the Coumadin clinic); aspirin 81 mg; Norvasc 5 mg; and Plavix 75 mg.  (He was taking Monopril until a couple of weeks ago when his doctor suggested we discontinue it.)
Originally, I was giving him all of his meds in the morning (except the Coumadin which is scheduled for 6 pm), after which he was not very responsive and tended to sleep all day, only reviving as evening approached.  After talking to the pharmacist about the situation, I started giving him his Norvasc in the evening and it helped a little.  His night time BP is a little lower, but his day time BP is still too low, usually about 95 over 69.  His night time BP tends to be 130-145/85-94. This week I've been moving other meds to night time, one at a time, trying to see if that would help.  
Changing the Isosorbide had no effect.  Today I held back the Atenolol, intending to give it to him tonight.  The only meds left to give him was the baby aspirin and the Plavix.  Initially after taking the meds, his BP dropped and he was temporarily groggy, but a half-hour later, it's up to 117/67 and he's pretty alert.
First, let me ask:  1) Is there any danger in rearranging his meds like this, and 2)why does he go backwards in his stroke recovery non-responsive, non-initiating)every time his BP goes down?
Also, he has had five episodes in which his BP drops like a rock to about 85/58, he is extremely diaphoretic, and he vomits a small amount, then he is extremely weak for a while.  The first time was in his doctor's office and they thought it had something to do with the nasalgastric tube he had in at the time (it's since been removed).  They x-rayed him and changed its position and dismissed the event.  The second time at home the weakness was so severe I called 911.  At the hospital, the doctors who knew him told us that if they went in to do diagnostic procedures they would put him in danger of having another stroke.  My husband declined the procedures so they could do nothing except adjust his meds and send him home.  Two weeks ago, he had two episodes in one day and last Sunday he had another one.  One doctor thinks maybe one of the blockages in his heart is trying to close off.  I've had someone suggest that he's having "silent" heart attacks, whatever they are.  My husband has no pain, no shortness of breath, reports no chest pressure or other symptoms you'd look for.  
I just wondered if anyone had seen episodes like this before.  Since the hospital can't do any procedures for him, I was told it's a waste of time to call 911, so I just give him support when it happens.  He was on hospice care, but he's doing so well he was discharged two weeks ago.  So now it's just me.  At this point, I'm concentrating on getting the meds straightened out, since it seems not much else can be done.  Could exertion be a factor in these episodes?  The first time was going to the doctor's office when he was still using a walker.  I'm not sure of the other times, but the last time he had taken a short walk and it was a really hot day.
Sorry this is so long.  Thanks for any info.

Posted by CCF CARDIO MD JMF on June 18, 1999 at 07:24:44
Dear janis,
There is always a risk benefit to all medications and in your husbands case with as many medications that he is on there are always the potential of drug drug interactions.  While it is not within the scope of this forum to give advise regarding medications or medication dosages, it is important that you do review this with your physician.  I might recommend a home blood pressure monitor to track your husbands blood pressure throughout the day and record this in a diary so that you can provide your physician with the most concrete information.  
In general, it is important to take medication as prescribed following the dosing schedule set  forth by your physician.  All medicines have optimal dosing schedules and if these are not followed, medications can be ineffective or even hazardous.  
I hope this information is useful.  I wish you and your husband the best of luck.