Mark Ilescu Case Study: Why Add Captopril? Hypertension Goals, ACE Inhibitor Rationale and Captopril and Metoprolol Teaching

Case study: Mark Ilescu, primary hypertension, diabetes and captopril

Mark Ilescu is a 44-year-old client with primary hypertension. His history includes type 1 diabetes mellitus with early signs of nephropathy and a myocardial infarction 2 years ago, treated since then with the beta-blocker metoprolol. He also takes hydrochlorothiazide. His blood pressure today is 138/92 mm Hg, consistent with his last three visits. His physician has added captopril.

1. Mark does not understand why he needs another medication when his systolic pressure is below 140 mm Hg. How should the nurse respond?
2. Discuss the rationale for choosing captopril in Mark’s case.
3. What should the nurse teach Mark to minimize adverse effects of captopril and metoprolol?

Original example for study purposes (about 700 words). Add your pharmacology textbook’s chapter on antihypertensives.

1. Responding to Mark’s Question

The nurse should acknowledge Mark’s concern and explain that his blood pressure is not at goal. Although his systolic reading is below 140, both numbers matter. His diastolic pressure of 92 mm Hg is elevated, and for a person with diabetes, kidney disease and previous heart attack, the target is lower than for the general population. Current guidelines recommend a treatment goal of less than 130/80 mm Hg for most adults with hypertension, including those with diabetes (American Diabetes Association Professional Practice Committee [ADA], 2025; Jones et al., 2025). Mark’s readings have been consistently above that goal for four visits, so this is not a one-time measurement.

A helpful response might be: “I can see why that’s confusing. Your top number is close, but your bottom number is 92, and with your diabetes, early kidney changes and heart history, your goal is below 130 over 80. Keeping your pressure lower protects your kidneys and heart, and captopril has extra benefits for your kidneys that your other medicines do not provide.” The nurse should then check Mark’s understanding, ask about home readings and adherence, and invite questions.

2. Rationale for Captopril

• Kidney protection. Captopril is an angiotensin-converting enzyme (ACE) inhibitor. By blocking the conversion of angiotensin I to angiotensin II, it dilates the efferent arteriole of the glomerulus, lowering pressure inside the glomerulus and reducing protein loss in the urine. This slows the progression of diabetic nephropathy, independent of its blood pressure effect. ACE inhibitors or ARBs are recommended for people with diabetes, hypertension and albuminuria (ADA, 2025). Captopril has specific evidence and an FDA indication for diabetic nephropathy in type 1 diabetes.
• Cardiac protection after MI. ACE inhibitors reduce afterload and help prevent adverse ventricular remodeling after myocardial infarction, lowering the risk of heart failure and recurrent cardiovascular events.
• Complementary mechanism. Captopril lowers blood pressure through a different pathway than metoprolol (which reduces heart rate and renin release) and hydrochlorothiazide (which reduces blood volume). ACE inhibitors also reduce aldosterone, which can offset thiazide-induced potassium loss. Combining drug classes usually controls blood pressure better than increasing one drug’s dose.
• Metabolic neutrality. ACE inhibitors do not worsen glucose or lipid levels, which is important in diabetes.

3. Teaching to Minimize Adverse Effects

Captopril

• Timing: take captopril 1 hour before meals, because food reduces its absorption, and take it at the same times each day.
• First-dose hypotension: the first doses can cause dizziness, especially with a diuretic. Rise slowly from lying or sitting, take the first dose at bedtime if instructed and report fainting.
• Dry cough: a persistent, nonproductive cough is common because of bradykinin buildup; report it rather than stopping the drug, since an ARB can be substituted.
• Angioedema: swelling of the lips, tongue, face or throat, or difficulty breathing, is an emergency; stop the drug and call 911.
• Hyperkalemia: avoid potassium supplements and salt substitutes containing potassium unless prescribed; report muscle weakness or irregular heartbeat. Expect blood tests for potassium and creatinine within 1 to 2 weeks after starting.
• Other: report sore throat or fever (rare neutropenia), rash or taste changes; avoid NSAIDs, which reduce effectiveness and can harm the kidneys; stay hydrated during vomiting or diarrhea; and avoid pregnancy, because ACE inhibitors cause fetal harm.

Metoprolol

• Do not stop suddenly. Abrupt withdrawal can cause rebound hypertension, chest pain or another MI; doses must be tapered by the provider.
• Check pulse and blood pressure before taking it, and report a heart rate below 60 beats per minute (or the provider’s limit), dizziness or fainting.
• Hypoglycemia masking: this is especially important for Mark’s type 1 diabetes. Beta-blockers can hide warning signs such as rapid heartbeat and tremor; sweating usually remains. Mark should check his blood glucose more often and treat lows promptly.
• Report shortness of breath, wheezing, swelling of the ankles or rapid weight gain (heart failure), fatigue, depression or sexual dysfunction.

General teaching: monitor and log blood pressure at home, follow a low-sodium, DASH-style diet, limit alcohol, exercise as approved, stop smoking if applicable, keep glucose within target, and change position slowly because the three drugs together increase the risk of orthostatic hypotension.

References

American Diabetes Association Professional Practice Committee. (2025). 10. Cardiovascular disease and risk management: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S207–S238. https://doi.org/10.2337/dc25-S010

Jones, D. W., Ferdinand, K. C., Taler, S. J., Johnson, H. M., Shimbo, D., Abdalla, M., Altieri, M. M., Bansal, N., Bello, N. A., Bress, A. P., Carter, J., Cohen, J. B., Collins, K. J., Commodore-Mensah, Y., Davis, L. L., Egan, B., Khan, S. S., Lloyd-Jones, D. M., Melnyk, B. M., . . . Ziai, W. C. (2025). 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Journal of the American College of Cardiology, 86(18), 1567–1678. https://doi.org/10.1016/j.jacc.2025.05.007

[Your pharmacology textbook, in APA format.]

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