incorrect heart medication?

[Abeybaby]

Tks for taking my questions. My father, age, 65, diagnosis of left ventricular hypertrophy, caused by high blood pressure. Now a controlled type two diabetic on glaucophage and lipid levels are normal. It was believed that when he was 30, his heart was enlarged back then so dr felt he might have had rhuematic fever from the old country prior to the onset of high bp.Note no prior heart attacks but has fainted on two occassions- he says he has an arrythmia, I believehe suffers from PVC as well. Can't tell what stage of CHF he's at but is extremely active and never feels tired.  So here are my questions:
He is on a drug called logimax which is a combination of beta blocker and calcium channel blocker and has been on this for 10 yrs. A close friend, who is a cardiologist indicated that this is the wrong meds for his condition. He does get swelling in the ankle area. Said he should be taking: a duiretic low dose to start and a ACE inhibitor or perhaps COZAR? Is this correct?

Second- the fact that he is diabetic should his meds reflect this condition and if so what meds are typically given?

Third- what would be a first line defence given to patient like him given his profile? Tks very much! He is located in Greece and I don't much trust them there and is comming to Canada for a second oppinion?

[CCF-M.D.-MJM]

Hello,

Answers to questions like this are difficult.

First of all, the most important aspect of your fathers care is to control his blood pressure.  There are differences in the agents that can be used and there are different reasons to use these agents. It is also important to note that the medications that were recommended a few years ago may not be the medications recommended now.

My first line of therapy for someone with hypertension, LVH and diabetes is a an ACEI.  If he develops a cough, I would then replace the ACEI with an ARB.

If the ACEI was not sufficient to control blood pressure I would add a calcium channel blocker.  The reason why is because beta blockers are not longer considered first line against hypertension -- they were a few years ago though.  Beta blockers alone are not great agents at controlling blood pressure and there is some evidence to suggest that beta blockers increase the incidence of diabetes.  I would not use a diuretic because of increasing evidence that diuretics by way of lowering potassium may also increase the risk of diabetes.  Your father already had diabetes so this may be a mute point (or moooo point if you watch the TV show friends), but this would be my approach.

This is not the only approach and I promise you if you ask around you will hear different opinions.  There is good evidence to suggest that an ACEI should be the first agent because of the diabetes (HOPE study) and LVH.

Incidently, the threshold for starting a diabetic on an lipid agent is very low.  I would probably start a statin on a patient with hypertension and diabetes if the LDL is not lower than 80.  Again, opinions on this may vary.

I hope this answers your questions.  Good luck and thanks for posting.

[mmfd]

Just in case you didn't know, the guidelines limit us to 2 questions in a 6 month period.  Just a friendly reminder!