Patient with Essential Hypertension and Diastolic Dysfunction




(1)
Department of Clinical and Molecular Medicine, University of Rome Sapienza St Andrea Hospital, Rome, Italy

 




2.1 Clinical Case Presentation


A 44-year-old, Caucasian male, officer, presented to the Outpatient Clinic for clinical assessment of uncontrolled essential hypertension.

He has history of essential hypertension by about 15 years. At the first diagnostic examination, all screening tests have excluded secondary forms of hypertension, thus confirming the primary nature of the disease. Then, he was treated with a combination therapy based on ACE inhibitor (enalapril 10 mg) and calcium-channel blocker (nifedipine slow release 30 mg).

About 5 years ago, for incoming lower limb oedema, he was moved to another calcium-channel blocker (from nifedipine SR 30 mg to lercanidipine 10 mg), with satisfactory BP control at home and no relevant side effects or adverse reactions.

By about 8 months, he reported uncontrolled BP levels measured at home and effort dyspnoea. He also described frequent palpitations and tachycardia. For these reasons, his referring physician firstly titrated the dosage of enalapril from 10 to 20 mg daily and then added a thiazide diuretic (hydrochlorothiazide 25 mg daily) to current pharmacological therapy, albeit with limited improvement on BP control and persistent dyspnoea.


Family History


He has paternal history of coronary artery disease and maternal history of hypertension and myocardial infarction. He also has two sisters with hypertension.


Clinical History


He was previously a smoker (more than 20 cigarettes daily) for more than 20 years until the age of 38 years, when chronic obstructive pulmonary disease with a predominant asthmatic component was diagnosed. He also has additional modifiable cardiovascular risk factors, including mild hypercholesterolemia treated with simvastatin 10 mg daily and hypertriglyceridemia treated with fibrates. There are no additional cardiovascular risk factors or concomitant cardiovascular or non-cardiovascular comorbidities.


Physical Examination






  • Weight: 87 kg


  • Height: 185 cm


  • Body mass index (BMI): 25.4 kg/m2


  • Waist circumference: 98 cm


  • Respiration: normal


  • Heart sounds: distal cardiac sounds with apparently free intervals


  • Resting pulse: regular rhythm with normal heart rate (75 beats/min)


  • Carotid arteries: no murmurs


  • Femoral and foot arteries: palpable


Haematological Profile






  • Haemoglobin: 13.8 g/dL


  • Haematocrit: 47.2 %


  • Fasting plasma glucose: 66 mg/dL


  • Fasting lipids: total cholesterol (TOT-C): 169 mg/dl; low-density lipoprotein cholesterol (LDL-C): 105 mg/dl; high-density lipoprotein cholesterol (HDL-C), 43 mg/dl; triglycerides (TG) 104 mg/dl


  • Electrolytes: sodium, 141 mEq/L; potassium, 4.3 mEq/L


  • Serum uric acid: 3.6 mg/dL


  • Renal function: urea, 25 mg/dl; creatinine, 1.2 mg/dL; creatinine clearance (Cockcroft–Gault), 97 ml/min; estimated glomerular filtration rate (eGFR) (MDRD), 75 mL/min/1.73 m2


  • Urine analysis (dipstick): normal


  • Albuminuria: 14.7 mg/24 h


  • Normal liver function tests


  • Normal thyroid function tests


Blood Pressure Profile






  • Home BP (average): 150/100 mmHg


  • Sitting BP: 153/104 mmHg (right arm); 156/106 mmHg (left arm)


  • Standing BP: 157/105 mmHg at 1 min


  • 24-h BP: 149/101 mmHg; HR: 67 bpm


  • Daytime BP: 135/105 mmHg; HR: 69 bpm


  • Night-time BP: 138/92 mmHg; HR: 60 bpm

The 24-h ambulatory blood pressure profile is illustrated in Fig. 2.1.

A335263_1_En_2_Fig1_HTML.gif


Figure 2.1
24-h ambulatory blood pressure profile at first visit


12-Lead Electrocardiogram


Sinus rhythm with normal heart rate (78 bpm), normal atrioventricular conduction with right bundle branch block (Fig. 2.2)

A335263_1_En_2_Fig2_HTML.gif


Figure 2.2
12-lead electrocardiogram at first visit: sinus rhythm with normal heart rate (78 bpm), normal atrioventricular conduction with right bundle branch block. Peripheral (a) and precordial (b) leads


Vascular Ultrasound






  • Carotid: intima–media thickness at both carotid levels (right: 0.7 mm, and left: 0.8 mm)) without evidence of atherosclerotic plaques


  • Renal: intima–media thickness at both renal arteries without evidence of atherosclerotic plaques. Normal Doppler examination at both right and left arteries. Normal dimension and structure of the abdominal aorta


Current Treatment


Enalapril 20 mg h 8:00; hydrochlorothiazide 25 mg h 8:00; lercanidipine 10 mg h 20:00


Diagnosis


Essential (stage 2) hypertension with unsatisfactory BP control on combination therapy. Additional modifiable cardiovascular risk factors (hypercholesterolemia and hypertriglyceridemia). No evidence of hypertension-related organ damage nor associated 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. dihydropyridinic calcium antagonist).

 

2.

Add another drug class (e.g. beta-blocker).

 

3.

Switch from ACE inhibitor to ARB combined with thiazide diuretic.

 

4.

Switch from ACE inhibitor to direct renin inhibitor combined with thiazide diuretic.

 


Treatment Evaluation






  • Add beta-blocker at medium dose (atenolol 100 mg ¼ cp h 8:00 and ¼ cp h 20:00).


  • Maintain enalapril 20 mg h 8:00, hydrochlorothiazide 25 mg h 8:00 and lercanidipine 10 mg h 20:00.


Prescriptions






  • Periodical BP evaluation at home according to recommendations from guidelines


  • Echocardiogram aimed at evaluating left ventricular (LV) mass and function (systolic and diastolic properties)


2.2 Follow-Up (Visit 1) at 6 Weeks


At follow-up visit, the patient is in good clinical condition. However, he referred to have prematurely stopped the prescribed therapy with beta-blocker due to perceived deterioration of effort dyspnoea and asthma. He also tried to double the dose of amlodipine 5 mg twice daily, but even in this case, he has to prematurely stop this additional medication due to onset of lower limb oedema and frequent palpitations. For these reasons, he maintained his previous antihypertensive therapy without adverse reactions or drug-related side effects, although the BP levels measured at home remained substantially unchanged.


Physical Examination






  • Respiration: normal


  • Heart sounds: distal cardiac sounds with apparently free intervals


  • Resting pulse: regular rhythm with normal heart rate (74 beats/min)


  • Other clinical parameters substantially unchanged


Blood Pressure Profile






  • Home BP (average): 150/100 mmHg


  • Sitting BP: 154/102 mmHg (right arm); 155/104 mmHg (left arm)


  • Standing BP: 156/105 mmHg at 1 min


Current Treatment


Enalapril 20 mg h 8:00; hydrochlorothiazide 25 mg h 8:00; lercanidipine 10 mg h 20:00


Echocardiogram


Concentric remodelling (LV mass indexed 108 g/m2; relative wall thickness: 0.43) with normal chamber dimension (LV end-diastolic diameter 50 mm) (Fig. 2.3a), impaired LV relaxation at both conventional (E/A ratio <1; Fig. 2.3b) and tissue Doppler evaluations and normal ejection fraction (LV ejection fraction 60 %). In particular, tissue Doppler analysis was performed at both lateral wall of the LV (Fig. 2.3c) and interventricular septum (Fig. 2.3d).
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Jul 17, 2017 | Posted by in NEPHROLOGY | Comments Off on Patient with Essential Hypertension and Diastolic Dysfunction

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