Question: dear doctor

My dad aged 96 .active person for his age.known hypertensive for the last 20 years .taking anti-hypertensives as per docs adv.Family physicians keep changing medicines as & when they felt. last 4 or 5 years he has been on TelmaH-40 only.earlier he was taking Telma-Am also. he always has swelling on one of the legs and since doc felt amlodopine could aggravate switched over to TELMA H-40.

with Telma H 40 also there is is definite accumulation of fluid on one of the legs around foot area .this has been going on for the last 3 years.

apart from TelmaH 40 he was asked to take Dytor 5 mg also.

recently last 4 months dytor is increased to 10 Mg once daily.

apart from these 3 medicines,he takes NICORADIL 5 mg once daily in morning, roseday F 5mg, clopilet 75mg once daily along with vitamins.

he does all his routine work himself and was able to walk to nearby temple also.

he always weighs 51-52 kgs.

we always measure BP using OMRON BP instrument at home and he records around 65/130 to 70/140 or 150 at times. he used to have beats around 70-75 range.

with all these background now I come to the problem.

last 15 days back he started having shortness of breath even at rest also at home and we measured the BP. BP was around 160/75 and pulse was also on the higher side around 78 to 85.

we consulted with ourl MD Physician who took ECG and said age releated issues and nothing abnormal.Doc suggested to first control the BP(when Doc took the BP with his mercurial appart

us he recorded165/90).so he suggested to take Telepress CT 12,5--(telmiartan 80 MG plus 12.5 mg chlorthalidone) daily once and added ABphyline retard tab one in morning and 1 in night plus inhaler 2 times a day.After 3 or 4 days of this we continued to check BP at home and BP was still not coming down and patient felt only slightly better .Infact the Pulse at sometimes went as high as 86 and all.

we also have a local lady physician near by our home who after coming home said first to take ECHO & chest X ray and show to the MD physician. we took ECHO and X ray ( reports enclosed).and when showed to the MD doc--doc said all are age related issues only and continue same -- I.e Telma80 mg with 12,5 chlor.. and all other regular medicines. he suggested to taper ab phyline retard to 1 per day if shorntess/breathlessness improves.

Last sunday evening around 6 PM even after taking the above 80MG telma BP was around 160 /85 at home.. since being sunday evening we gave half of Telma 80 again to keep BP under control.

monday morning .. 21/11 while he was jus reading newspaper around & 7.30 AM he suddenly felt for a second chillness on the heart portion (only for a sec) with which he felt uncomfortable saying some chillness he felt. we immediately checked the BP at home and recorded 165/85 with pulse rate at 85.

so to control the Pulse rate we gave prolomet XL- 25 Mg and also half of Telma 80.

we called the local physican at home and she checked for any heart attack like symptoms and said nothing of that sort as there was no pain/ sweating etc.we narrated the medicine what we we were giving to her. she also went thro the ECHO and said age related but suggested the following change of medicines.

1) TELMA 40 H--1 in morning

2)prolomet--XL 25 MG --1 in morning

3)Prolomet --Xl- 12.5 mg--1 in night

4)nicorandil--5 mg--1 in morning & 1 in night.

5)DYtor--10 Mgin the morning.

6)restil-5 mg at night.

7) clopilet 75 mg at night.

she said BP & pulse has to under control and nicorandil additional in the night to take of moderate pulmonary hypertension.she also suggested to continue AB phyline retard till condition improves.

with the above changes last 3 days dad is doing much better and breathlessness also has come down.

infact BP came to around 135/65 and pulse around 65-70 .

last night BP touched again to 150/75 but patient had no complaint.

Today morning around 6AM dad again felt little uncomfortable at the chest area only ( no pain or sweating )while walking inside home and we checked BP immediately. it was 140/60 and pulse at 65.

we told him to lie down on bed and relax.

around 9 am we checked BP again--it was 135/65 with pulse around 67.he felt much better.

is the above medical management correct?

there is a difference of opinion in suggesting TELMA 80 MG with 12.5 chlor..by the MD DOC with our local lady physician who included prolomet XL 25 and 12,5 and suggested to increase Nicorandil 5 mg in the night also .

my father wants the breathlessness to come down and he never had this type of BP or pulse shooting in the past.

amlodopine was discontinued becoz of swelling on the legs.

kindly go through the above patiently .

I am enclsoing the ECHO & Chest X ray which is taken last week and also the same ECHO and Chest X ray report which we took 6 years back for COMPARISON study.

kindly go thro the both report and suggest us whether the medical management what we are presenly doing is correct and any changes/alterations/dosage changes need to be done.

Dad is always a active person for his age and does not want to get confined to bed only.

NOTE-- apart from swelling of one leg--he developed slight swelling on the other leg also .becoz of this di uretics --he is urinating well and swelling is there now on only one leg only.

his serum creatinine is 2.01 .creatinine for very long was around 1.8 only and when we checked in july creatinine is 2.01.for whcih he is taking nephosave one per day.

looking forward to your advice.

Best regrds

XXXXX

dear docotor
thanx for the response.I still have few questions.
1) while we continue the above drug regimen, the local doctor suggested to remove prolometxl (metoprolol )-25 Mg and give only 12.5 mg in the night.Dad is stable and no untoward incident so far. Logic from local doctor is to maintain pulse rate between 65-70.is this right approach? on verifying daily.... pulse is stabilizing at around 70. she further said mild dose of beta blockers helps a lot in dystolic dysfunction till grade 2. Is this correct??
2) she said Nicorandil -5 mg in the night also will help in improving the patients moderate pulmonary hypertension which of course is age related as per her. Is this approach right since Nicorandil has been increased to twice a day.
3) we forgot to mention that dad is taking ABphyline Retard tablet one per day for breathlessness .Should we continue the same or discontinue once patient is fine.?
4) in the event of any sudden surge in BP to the levels of 170/90 what medicine would you suggest??
5)for general weakness would IM decadurobolin injection help in elderly? in the last 6 months dad was given twice so far and local doctor saying will inject again next week.
kindly clarify the above.
Thanx again.

dear doctor
many thanks for answering. my last follow up queries as below.
1)what type of diet you recommend considering the fluid accumulation in one of the legs.
2) does the present Di uretics sufficient or to add any more? if further accumulation should we increase dytor doasge to 20 MG? or any alternative?
3)in the event of sudden surge should I give Temisartan or Metoprolol?? which one will act faster to bring normalcy?will Nicorandil 5 Mg act faster to bring down pressure because of dilatory effect???
4) what would be the suggested bandwith of BP & pulse rate to maintain?
DAD read all your replies and thrilled to note the recommendations given by you.
5)what really is the effect of DECADURABOLIN-IM Injection? how often shd be given to elderly ?
he has been stable so far without any untoward incidents.last night before dinner I measured BP and noted 130/65 with pulse rate at 69.he himself feeling relaxed and like to strat slowly his normal activities.
Kindly advise.
DAD wants to thankyou for patiently replying to the queries.
Best Regards,
note-- we are in the southern part of XXXXXXX in XXXXXXX