(1)
Department of Clinical and Molecular Medicine, University of Rome Sapienza St Andrea Hospital, Rome, Italy
5.1 Clinical Case Presentation
A 77-year-old, Caucasian female, housewife, presented to the Outpatient Clinic for recently uncontrolled hypertension.
She has history of essential hypertension by more than 30 years, treated with combination therapy with beta-blocker and thiazide diuretic (nebivolol/HCTZ 5/12.5 mg) and ACE inhibitor (lisinopril 10 mg).
By about 6 months, she reported uncontrolled BP levels measured at home and at general practitioner. For this reason, her referring physician firstly titrated the dosage of thiazide diuretic from 12.5 to 25 mg combined with the beta-blocker nebivolol 5 mg and the prescribed a dihydropyridinic calcium-channel blocker (lacidipine 6 mg daily) in addition to current pharmacological therapy. However, the patient referred persistently high BP levels at home; she also described a relatively frequent missing assumption of some drugs, due to high pills’ burden.
Family History
She has paternal history of hypertension and stroke and maternal history of dyslipidaemia.
Clinical History
She was previous a smoker by more than 35 years (20 cigarettes daily). She was affected by hypercholesterolaemia initially treated with atorvastatin 20–40 mg and now treated with rosuvastatin 5 mg daily. There are no other additional cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.
Physical Examination
Weight: 55 kg
Height: 160 cm
Body mass index (BMI): 21.5 kg/m2
Waist circumference: 88 cm
Respiration: normal
Heart sounds: S1–S2 regular, normal, no murmurs
Resting pulse: regular rhythm with normal heart rate (68 beats/min)
Carotid arteries: right bruit
Femoral and foot arteries: palpable
Haematological Profile
Haemoglobin: 15.0 g/dL
Haematocrit: 54.7 %
Fasting plasma glucose: 91 mg/dL
Fasting lipids: total cholesterol (TOT-C), 186 mg/dl; low-density lipoprotein cholesterol (LDL-C), 126 mg/dl; high-density lipoprotein cholesterol (HDL-C), 44 mg/dl; triglycerides (TG) 132 mg/dl
Electrolytes: sodium, 146 mEq/L; potassium, 4.1 mEq/L
Serum uric acid: 4.1 mg/dL
Renal function: urea, 20 mg/dl; creatinine, 0.5 mg/dL; creatinine clearance (Cockcroft–Gault), 81 ml/mn; estimated glomerular filtration rate (eGFR) (MDRD), 129 mL/min/1.73 m2
Urine analysis (dipstick): proteinuria 5 mg/dl
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 150/100 mmHg
Sitting BP: 145/106 mmHg (right arm); 144/108 mmHg (left arm)
Standing BP: 151/107 mmHg at 1 min
24-h BP: 144/104 mmHg; HR: 77 bpm
Daytime BP: 145/106 mmHg; HR: 79 bpm
Night-time BP: 138/94 mmHg; HR: 65 bpm
The 24-h ambulatory blood pressure profile is illustrated in Fig. 5.1.
Figure 5.1
24-h ambulatory blood pressure profile at first visit
12-Lead Electrocardiogram
Sinus rhythm with normal heart rate (70 bpm), normal atrioventricular and intraventricular conduction, no ST-segment abnormalities or signs of LVH (aVL 0.3 mV; Sokolow–Lyon: 2.5 mV; Cornell voltage 0.7 mV; Cornell product 67.9 mV*ms) (Fig. 5.2).
Figure 5.2
12-lead electrocardiogram at first visit: sinus rhythm with normal heart rate (70 bpm), normal atrioventricular and intraventricular conduction, no ST-segment abnormalities or signs of LVH. Peripheral (a) and precordial (b) leads
Echocardiogram with Doppler Ultrasound
Normal LV geometry (LV mass indexed 88 g/m2; relative wall thickness: 0.37) with normal chamber dimension (LV end-diastolic diameter 47 mm) (Fig. 5.3a), normal LV relaxation (E/A ratio 2.1) at conventional Doppler evaluation and normal ejection fraction (LV ejection fraction 67 %, LV fractional shortening 37 %). Normal dimensions of aortic root and left atrium. Right ventricle with normal dimension and function. Pericardium without relevant abnormalities.
Figure 5.3
Echocardiogram with Doppler ultrasound at first visit: normal LV geometry with normal chamber dimension (a), normal LV relaxation at conventional Doppler evaluation (b) and normal ejection fraction. Normal dimensions of aortic root and left atrium. Right ventricle with normal dimension and function. Pericardium without relevant abnormalities. Mitral (+) regurgitation at Doppler ultrasound examination
Mitral (+) regurgitation at Doppler ultrasound examination.
Current Treatment
Lisinopril 10 mg h 8:00; nebivolol/HCTZ 5/25 mg h 12:00; lacidipine 6 mg h 20:00; aspirin 100 mg h 12:00; rosuvastatin 5 mg h 22:00
Diagnosis
Essential (stage 2) hypertension with unsatisfactory BP control on combination therapy. No evidence hypertension-related cardiac and renal organ damage. One additional modifiable cardiovascular risk factors, i.e. hypercholesterolaemia. No other relevant clinical conditions
Which is the global cardiovascular risk profile in this patient?
Possible answers are:
1.
Low
2.
Medium
3.
High
4.
Very high
Global Cardiovascular Risk Stratification
According to 2013 ESH/ESC global cardiovascular risk stratification [1], this patient has moderate to high cardiovascular risk.
Which is the best therapeutic option in this patient?
Possible answers are:
1.
Add another drug class (e.g. loop diuretic).
2.
Add another drug class (e.g. antialdosterone agent).
3.
Titrate current therapy and switch to long-lasting agents.
4.
Switch from ACE inhibitor to angiotensin receptor blocker.
5.
Switch from ACE inhibitor to direct renin inhibitor.
Treatment Evaluation
Stop lisinopril 10 mg and lacidipine 6 mg.
Start fixed combination with perindopril/amlodipine 5/5 mg h 20:00.
Maintain nebivolol/HCTZ 5/25 mg h 8:00, aspirin 100 mg h 12:00, rosuvastatin 5 mg h 22:00.
Prescriptions
Periodical BP evaluation at home according to recommendations from guidelines
Blood tests for lipid parameters, including total, LDL, HDL cholesterol and triglycerides
Carotid Doppler ultrasound examination to exclude the presence of vascular organ damage
5.2 Follow-Up (Visit 1) at 6 Weeks
At follow-up visit, the patient is in good clinical condition. She reported good adherence to prescribed medications without adverse reactions or drug-related side effects.
Physical Examination
Resting pulse: regular rhythm with normal heart rate (71 beats/min)
Other clinical parameters substantially unchanged
Blood Pressure Profile
Home BP (average): 145/95 mmHgRelated posts:
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