(1)
Department of Clinical and Molecular Medicine, University of Rome Sapienza St Andrea Hospital, Rome, Italy
1.1 Clinical Case Presentation
A 54-year-old, Caucasian male, gardener, presented to the outpatient clinic for recently uncontrolled hypertension.
He has history of essential hypertension by more than 15 years, initially treated with a combination therapy based on beta-blocker (atenolol 100 mg) and diuretic (chlorthalidone 25 mg).
About 10 years ago, for incoming asthenia and sexual disturbances, he was moved to a combination therapy based on angiotensin-converting enzyme (ACE) inhibitor (ramipril 10 mg) and thiazide diuretic (hydrochlorothiazide 25 mg), with satisfactory BP control at home and no relevant side effects or adverse reactions.
By about 6 months, he reported uncontrolled blood pressure (BP) levels measured at home and effort dyspnoea. He also described inconstant cough. For these reasons, his referring physician prescribed furosemide 25 mg daily in addition to current pharmacological therapy, albeit with limited improvement on BP control.
Family History
He has paternal history of hypertension and stroke and maternal history of diabetes and hypercholesterolemia. He also has one sibling with hypertension.
Clinical History
He was previous smoker (about 10–20 cigarettes daily) for more than 20 years until the age of 45 years. He also has two additional modifiable cardiovascular risk factors, including sedentary life habits and overweight (visceral obesity). There are no further cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.
Physical Examination
Weight: 88 kg
Height: 174 cm
Body mass index (BMI): 29.1 kg/m2
Waist circumference: 118 cm
Respiration: normal
Heart sounds: S1–S2 regular, normal and no murmurs
Resting pulse: regular rhythm with normal heart rate (67 beats/min)
Carotid arteries: no murmurs
Femoral and foot arteries: palpable
Haematological Profile
Haemoglobin: 15.1 g/dL
Haematocrit: 49.3 %
Fasting plasma glucose: 87 mg/dL
Fasting lipids: total cholesterol (TOT-C): 174 mg/dl; low-density lipoprotein cholesterol (LDL-C): 111 mg/dl; high-density lipoprotein cholesterol (HDL-C): 39 mg/dl; triglycerides (TG) 122 mg/dl
Electrolytes: sodium, 146 mEq/L; potassium, 4.2 mEq/L
Serum uric acid: 4.1 mg/dL
Renal function: urea 24 mg/dl, creatinine, 0.8 mg/dL; creatinine clearance (Cockcroft–Gault): 130 ml/min; estimated glomerular filtration rate (eGFR) (MDRD): 110 mL/min/1.73 m2
Urine analysis (dipstick): normal
Albuminuria: 12.2 mg/24 h
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 160–165/100 mmHg
Sitting BP: 164/106 mmHg (right arm); 166/107 mmHg (left arm)
Standing BP: 167/108 mmHg at 1 min
24-h BP: 161/112 mmHg; HR: 67 bpm
Daytime BP: 162/113 mmHg; HR: 71 bpm
Night-time BP: 154/103 mmHg; HR: 61 bpm
A 24-h ambulatory blood pressure profile is illustrated in Fig. 1.1.
Figure 1.1
24-h ambulatory blood pressure profile at first visit
12-Lead Electrocardiogram
Sinus rhythm with normal heart rate (63 bpm), normal atrioventricular and intraventricular conduction and ST-segment abnormalities without signs of LVH (aVL 0.7 mV, Sokolow–Lyon 2.1 mV, Cornell voltage 1.4 mV, Cornell product 130 mV*ms) (Fig. 1.2).
Figure 1.2
(a, b) Sinus rhythm with normal heart rate (63 bpm), normal atrioventricular and intraventricular conduction and ST-segment abnormalities without signs of LVH
Vascular Ultrasound
Carotid: Intima–media thickness at both carotid levels (right, 1.0 mm, Fig. 1.3a; left, 0.9 mm, Fig. 1.3b) without evidence of atherosclerotic plaques.
Figure 1.3
Intima–media thickness at both carotid levels (right, 1.0 mm (a); left, 0.9 mm (b), 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
Ramipril 10 mg h 8:00, hydrochlorothiazide 25 mg h 8:00 and furosemide 25 mg h 12:00.
Diagnosis
Essential (stage 2) hypertension with unsatisfactory BP control on combination therapy. Additional modifiable cardiovascular risk factors (sedentary habits and visceral obesity). 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.
Add another drug class (e.g. alpha-blocker).
4.
Switch from ACE inhibitor to angiotensin receptor blocker combined with thiazide diuretic.
5.
Switch from ACE inhibitor to direct renin inhibitor combined with thiazide diuretic.
Treatment Evaluation
Stop ACE inhibitor ramipril 10 mg and furosemide 25 mg.
Start fixed combination therapy with losartan/hydrochlorothiazide 100/25 mg h 8:00.
Prescriptions
Periodical BP evaluation at home according to recommendations from guidelines
Regular physical activity and low caloric intake
Echocardiogram aimed at evaluating left ventricular (LV) mass and function (systolic and diastolic properties)
1.2 Follow-Up (Visit 1) at 6 Weeks
At follow-up visit the patient is in good clinical condition. He started moderate physical activity two times per week with beneficial effects (weight loss and relatively good exercise tolerance). He also reported good adherence to prescribed medications without adverse reactions or drug-related side effects (absence of cough and improved dyspnoea).
Physical Examination
Weight: 86 kg
BMI: 28.1 kg/m2
Waist circumference: 114 cm
Resting pulse: regular rhythm with normal heart rate (65 beats/min)
Other clinical parameters substantially unchanged
Blood Pressure Profile
Home BP (average): 155/90 mmHg (early morning)
Sitting BP: 158/92 mmHg (left arm)
Standing BP: 158/94 mmHg at 1 min
Current Treatment
Losartan/hydrochlorothiazide 100/25 mg h 8:00.
Echocardiogram
Concentric LV hypertrophy (LV mass indexed 128 g/m2, relative wall thickness 0.53) with normal chamber dimension (LV end-diastolic diameter 49 mm) (Fig. 1.4a), impaired LV relaxation (E/A ratio <1) at both conventional (Fig. 1.4b) and tissue (Fig. 1.4c) Doppler evaluations and normal ejection fraction (LV ejection fraction 66 %, LV fractional shortening 37 %). Normal dimension of aortic root and left atrium. Right ventricle with normal dimension and function. Pericardium without relevant abnormalities.
Figure 1.4
Echocardiogram at follow-up visit after 6 weeks. Concentric LV hypertrophy with normal chamber dimension (a), impaired LV relaxation at both conventional (b) and tissue (c)
Mitral (++) and tricuspid (+) regurgitations at Doppler ultrasound examination.
Diagnosis
Essential (stage 2) hypertension with improved BP control on combination therapy without achieving the recommended BP targets. Cardiac organ damage (concentric LV hypertrophy) and impaired LV relaxation. Additional cardiovascular risk factors (visceral obesity).
Which is the global cardiovascular risk profile in this patient?
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