Help me with patient with unstable diastolic blood pressure

So one of my patients recently developed a low diastolic blood pressure (I'm a home health nurse) and it is strange.She is on 3 blood pressure meds (ACE inhibitor (Captopril),beta-blocker mixed with diuretic(Tenoretic),and a calcium channnel blocker (amlodipine) and a drug dipyridamole which is known to also decrease the blood pressure and had anticlotting properties.She also takes glyburide for diabetes and lovastatin for her hypercholestermia.The fist time I visit her at home,her BP was within normal range.That day she informed me that couple weeks ago she fainted and was taken to a hospital.The lady is not overweight,she weight 130 pounds.She is also diabetic and has some problems with eating because she is waiting for her dentures to be fixed.I orginally thought that the reason for her fainting was hypoglycemia but also I'm aware that she is on 3 blood pressure meds and also on another blood-pressure lowering drug Dipyridamole,although its action seems kinda confusing to me although I know for sure that when given in high doses they dilate blood vessels significantly,altough my patient is not on high dose but not at the lowest either.So Monday I saw the patient and her blood pressure was 132/55,pulse 60.Patient was asymptomatic.I notified MD,he said to hold Captopril and Amlodipine temporarly,increase frequency of visit,monitor BP,so the patient stopped taking the captopril and amlodpine as ordered,I made an appointment with her for today.So I come in today and patient states she feels fine,I checked her blood pressure it was 142/50.So her systolic increased 10 and diastolic decreased by 5.I'm calling MD again of course he did not call me back yet.Its been like 2.5 hours.His secretary havent even called me back.In your opinion what would be the reason for her low diastolic pressure.Any tips suggestions,thanks.
That's why your medical director gets paid the big bucks.

I think you need to wait for the doctor to call back.

Quote from roser13I think you need to wait for the doctor to call back.

You don't say what her pressure usually ran, so it is hard to know what to tell you. I have had more than a few patients with diastolic pressures in the 50's.Always call your clinical manager to keep them up with what is going on. And ask the doc to fax the orders into your office.

Quote from mamamerleeYou don't say what her pressure usually ran, so it is hard to know what to tell you. I have had more than a few patients with diastolic pressures in the 50's.Always call your clinical manager to keep them up with what is going on. And ask the doc to fax the orders into your office.

We're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

Quote from JulieCVICURNWe're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

Is this change noted with the same BP cuff.? has it been dropped or exposed to other potential damage?bring another one for next visit and compare. Take pressure on other arm. Was this noted before her fainting episode?

Quote from JulieCVICURNWe're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

Quote from morteIs this change noted with the same BP cuff.? has it been dropped or exposed to other potential damage?bring another one for next visit and compare. Take pressure on other arm. Was this noted before her fainting episode?

That's an interesting parameter. I've never had a cardiologist or a primary ask me to notify them about any low diastolics. I wonder what that particular doctor is up to, because that seems strange to me. Maybe he's trying to catch early heart failure symptoms or something.

The syncopal event (a few weeks ago) likely has nothing to do with her borderline low DBP that she has currently. As other posters have mentioned, her MAP is just fine and at the time you took her blood pressure, she was obviously tolerating it fine- alert, warm, and dry. There are too many possibilities for folks on the internet to speculate the cause of syncope for this particular patient and whether her current medication regimen really ought to be messed with. Those concerns are best discussed with her primary physician, and you don't need to fret if he doesn't get back to you pronto as she's not unstable, and if she really were, you'd be contacting EMS first, anyway. If you want to keep some possibilities in mind for general purposes, you could assess for orthostatic hypotension. Check her BP when she is lying, then sitting, then standing. Drops of more than 20 mmHg in the systolic pressure are what you would be concerned about. Syncope is also commonly caused by dysrhythmias. If this is a concern, then further workup is needed before changing treatment. You reported her change in vital signs as outside the parameters per protocol, and that was the appropriate thing to do. For specific questions regarding her particular case, definitely ask her primary, but again, don't worry if it is not an immediate response.