Patient with Essential Hypertension and High Pulse Pressure




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

 




6.1 Clinical Case Presentation


An 81-year-old, Caucasian male, former CEO of chemical company, presented to the Outpatient Clinic for uncontrolled systolic hypertension.

He has history of essential, isolated systolic hypertension by more than 20 years, treated with a combination therapy based on ACE inhibitor (ramipril 10 mg), diuretic (furosemide 25 mg), beta-blocker (bisoprolol 2.5 mg) and alpha-blocker (doxazosin 4 mg).

About 10 years ago, he was switched from ACE inhibitor to angiotensin receptor blocker (losartan 100 mg) for uncontrolled BP levels and evidence of cardiac organ damage (namely, LV hypertrophy). He was also stropped from calcium-channel blocker (nifedipine slow release 30 mg), due to lower limb oedema, palpitations and persistently uncontrolled BP levels, and then moved to alpha-blocker (doxazosin 4 mg) without relevant side effects, although with limited improvement of blood pressure (BP) control.

By about 6 months, he reported markedly uncontrolled BP levels measured at home, particularly for the systolic and during the early morning. Thus, his referring physician prescribed to doubling the dosage of doxazosin 4 mg twice daily in addition to current pharmacological therapy, albeit with persistently high systolic BP levels at home. He also described symptomatic hypotension.


Family History


He has paternal history of hypertension and stroke and maternal history of hypertension and diabetes. He also has one brother and one sister with hypertension and one sister with coronary artery disease.


Clinical History


He was a previous smoker (about 10–20 cigarettes daily) for more than 30 years until the age of 60 years. He also has two additional modifiable cardiovascular risk factors, including overweight (visceral obesity) and hypercholesterolaemia treated with simvastatin 20 mg. There were no further cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.

He reported regular physical activity (1-h aerobic section 2–3 times per week). For this reason, his referring physician prescribed electrocardiogram and blood tests annually, as well as echocardiogram and exercise stress test every 2–3 years in the absence of specific signs or symptoms of effort dyspnoea or angina.


Physical Examination






  • Weight: 86 kg


  • Height: 178 cm


  • Body mass index (BMI): 27.1 kg/m2


  • Waist circumference: 114 cm


  • Respiration: normal


  • Heart sounds: S1–S2 regular, normal, no murmurs


  • Resting pulse: regular rhythm with normal heart rate (62 beats/min)


  • Carotid arteries: no murmurs


  • Femoral and foot arteries: palpable


Haematological Profile






  • Haemoglobin: 14.3 g/dL


  • Haematocrit: 50.2 %


  • Fasting plasma glucose: 76 mg/dL


  • Fasting lipids: total cholesterol (TOT-C), 168 mg/dl; low-density lipoprotein cholesterol (LDL-C), 100 mg/dl; high-density lipoprotein cholesterol (HDL-C), 41 mg/dl; triglycerides (TG) 138 mg/dl


  • Electrolytes: sodium, 142 mEq/L; potassium, 4.0 mEq/L


  • Serum uric acid: 5.1 mg/dL


  • Renal function: urea, 26 mg/dl; creatinine, 1.0 mg/dL; creatinine clearance (Cockcroft–Gault), 71 ml/min; estimated glomerular filtration rate (eGFR) (MDRD), 80 mL/min/1.73 m2


  • Urine analysis (dipstick): proteinuria 10 mg/dl


  • Normal liver function tests


  • Normal thyroid function tests


Blood Pressure Profile






  • Home BP (average): 150–160/70 mmHg


  • Sitting BP: 168/75 mmHg (right arm); 166/78 mmHg (left arm)


  • Standing BP: 160/78 mmHg at 1 min


  • 24-h BP: 150/79 mmHg; HR: 81 bpm


  • Daytime BP: 146/78 mmHg; HR: 83 bpm


  • Night-time BP: 165/85 mmHg; HR: 72 bpm

The 24-h ambulatory blood pressure profile is illustrated in Fig. 6.1.

A335263_1_En_6_Fig1_HTML.gif


Figure 6.1
24-h ambulatory blood pressure profile at first visit


12-Lead Electrocardiogram


Sinus rhythm with normal heart rate (59 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities (reverse T waves) with signs of LVH (aVL 0.7 mV; Sokolow–Lyon, 3.8 mV; Cornell voltage 0.8 mV; Cornel product 81 mV*ms) (Fig. 6.2).

A335263_1_En_6_Fig2_HTML.gif


Figure 6.2
12-lead electrocardiogram at first visit: sinus rhythm with normal heart rate (59 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities (reverse T waves) with signs of LVH. Peripheral (a) and precordial (b) leads


Vascular Ultrasound






  • Carotid: intima–media thickness at both carotid levels (right: 1.1 mm, bilaterally) with evidence of fibro-calcific atherosclerotic plaque at carotid bifurcation and internal carotid artery without haemodynamic effects (Fig. 6.3)

    A335263_1_En_6_Fig3_HTML.jpg


    Figure 6.3
    Carotid ultrasound at first visit: intima–media thickness at both carotid levels (right: 1.1 mm, bilaterally) with evidence of fibro-calcific atherosclerotic plaque at carotid bifurcation and internal carotid artery without haemodynamic effects


  • 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


Echocardiogram


Eccentric LV hypertrophy (LV mass indexed 124 g/m2; relative wall thickness: 0.41) with high-normal chamber dimension (LV end-diastolic diameter 56 mm) (Fig. 6.4a), impaired LV relaxation (E/A ratio 1.1) at conventional (Fig. 6.4b) Doppler evaluations and normal ejection fraction (LV ejection fraction 77 %, LV fractional shortening 46 %). Normal dimension of aortic root. High-normal dimension of left atrium (diameter 40 mm, area 26 cm2). Right ventricle with normal dimension and function. Mild pericardial effusion without haemodynamic effects

A335263_1_En_6_Fig4_HTML.gif


Figure 6.4
Echocardiogram at first visit: eccentric LV hypertrophy with high-normal chamber dimension (a), impaired LV relaxation at conventional (b) Doppler evaluations and normal ejection fraction. Normal dimension of aortic root. High-normal dimension of left atrium. Right ventricle with normal dimension and function. Mild pericardial effusion without haemodynamic effects. Mitral (+) and tricuspid (+) regurgitations at Doppler ultrasound examination

Mitral (+) and tricuspid (+) regurgitations at Doppler ultrasound examination


Current Treatment


Losartan 100 mg h 8:00; furosemide 25 mg h 8:00; bisoprolol 2.5 mg h 8:00; aspirin 100 mg; doxazosin 4 mg h 22:00; simvastatin 20 mg h 22:00


Diagnosis


Essential (stage 2) hypertension and isolated systolic hypertension with unsatisfactory BP control on combination therapy. High pulse pressure. Additional modifiable cardiovascular risk factors, including visceral obesity and hypercholesterolaemia. Evidence of hypertension-related cardiac and vascular organ damage. No 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 high cardiovascular risk.


Which is the best therapeutic option in this patient?

Tags:
Jul 17, 2017 | Posted by in NEPHROLOGY | Comments Off on Patient with Essential Hypertension and High Pulse Pressure

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