(1)
Department of Clinical and Molecular Medicine, University of Rome Sapienza St Andrea Hospital, Rome, Italy
3.1 Clinical Case Presentation
A 45-year-old, Caucasian female, postal employee, presented to the Outpatient Clinic for recently uncontrolled hypertension.
She has history of essential hypertension and tachycardia by the age of 38 years. She was treated with monotherapy based on beta-blocker (atenololo 100 mg) with initially effective BP control.
By about 3 months, she reported uncontrolled diastolic BP levels measured at work. For this reason, her referring physician prescribed felodipine 10 mg daily in addition to the current pharmacological therapy. However, the patient was not disposed to adding another pill and asked for thorough assessment of her hypertension.
Family History
She has maternal history of hypertension and diabetes.
Clinical History
She is a smoker (about 10 cigarettes daily) for about 15 years, without other additional cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.
Physical Examination
Weight: 58 kg
Height: 170 cm
Body mass index (BMI): 20.1 kg/m2
Waist circumference: 88 cm
Respiration: normal
Heart sounds: S1–S2 regular, normal, systolic murmur at cardiac apex
Resting pulse: regular rhythm with normal heart rate (65 beats/min)
Carotid arteries: no murmurs
Femoral and foot arteries: palpable
Haematological Profile
Haemoglobin: 16.3 g/dL
Haematocrit: 52.1 %
Fasting plasma glucose: 88 mg/dL
Fasting lipids: total cholesterol (TOT-C), 164 mg/dl; low-density lipoprotein cholesterol (LDL-C), 84 mg/dl; high-density lipoprotein cholesterol (HDL-C), 65 mg/dl; triglycerides (TG) 78 mg/dl
Electrolytes: sodium, 145 mEq/L; potassium, 4.0 mEq/L
Serum uric acid: 2.6 mg/dL
Renal function: urea, 22 mg/dl; creatinine, 1.0 mg/dL; creatinine clearance (Cockcroft–Gault), 77 ml/min; estimated glomerular filtration rate (eGFR) (MDRD), 69 mL/min/1.73 m2
Urine analysis (dipstick): proteinuria 20 mg/dl
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 130/100 mmHg
Sitting BP: 145/98 mmHg (right arm); 142/96 mmHg (left arm)
Standing BP: 146/95 mmHg at 1 min
24-h BP: 131/91 mmHg; HR: 77 bpm
Daytime BP: 135/93 mmHg; HR: 78 bpm
Night-time BP: 122/85 mmHg; HR: 75 bpm
The 24-h ambulatory blood pressure profile is illustrated in Fig. 3.1.
Figure 3.1
24-h ambulatory blood pressure profile at first visit
12-Lead Electrocardiogram
Sinus rhythm with normal heart rate (65 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities without signs of LVH (aVL 0.3 mV; Sokolow–Lyon, 2.7 mV; Cornell voltage, 0.7 mV; Cornel product, 76.3 mV*ms) (Fig. 3.2)
Figure 3.2
12-lead electrocardiogram at first visit: sinus rhythm with normal heart rate (65 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities without signs of LVH. Peripheral (a) and precordial (b) leads
Echocardiogram with Doppler Ultrasound
Normal LV geometry (LV mass indexed 87 g/m2; relative wall thickness: 0.40) with normal chamber dimension (LV end-diastolic diameter 47 mm) (Fig. 3.3a), normal LV relaxation (E/A ratio 1.53) at both conventional (Fig. 3.3b) and tissue (Fig. 3.3c) Doppler evaluation and normal ejection fraction (LV ejection fraction 70 %). Normal dimensions of aortic root and left atrium. Right ventricle with normal dimension and function. Pericardium without relevant abnormalities
Figure 3.3
Echocardiogram with Doppler ultrasound at first visit: normal LV geometry with normal chamber dimension (a), normal LV relaxation at both conventional (b) and tissue (c) Doppler evaluation, 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
Vascular Ultrasound
Carotid: intima–media thickness at both carotid levels (right: 1.0 mm; left: 1.0 mm) without evidence of atherosclerotic plaques
Renal: intima–media thickness at both renal arteries without evidence of atherosclerotic plaques. Normal Doppler evaluation at both right (Fig. 3.4a) and left (Fig. 3.4b) renal arteries (main vessels and intraparenchymal arteries). Normal dimension and structure of the abdominal aorta
Figure 3.4
Renal vascular ultrasound at first visit: intima–media thickness at both renal arteries without evidence of atherosclerotic plaques. Normal Doppler evaluation at both right (a) and left (b) renal arteries (main vessels and intraparenchymal arteries). Normal dimension and structure of the abdominal aorta
Current Treatment
Atenolol 100 mg ½ cp h 8:00 and ½ cp h 20:00
Diagnosis
Essential (stage 1) hypertension with unsatisfactory BP control on monotherapy. No evidence of hypertension-related organ damage. No additional cardiovascular risk factors 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 low 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. thiazide diuretic).
3.
Add another drug class (e.g. ACE inhibitor).
4.
Add another drug class (e.g. ARB).
5.
Switch from beta-blocker to another drug class.
Treatment Evaluation
Gradually stop atenolol 100 mg.
Start irbesartan 150 mg h 8:00.
Prescriptions
Periodical BP evaluation at home according to recommendations from guidelines.
Stop smoking.
Blood and urinary tests for renal parameters, including serum creatinine, urea estimated glomerular filtration rate and creatinine clearance, and urinary albumin/creatinine ratio on morning urine sample
3.2 Follow-Up (Visit 1) at 6 Weeks
At follow-up visit, the patient is in good clinical condition. She does not stop smoking. However, she reported good adherence to prescribed medications without adverse reactions or drug-related side effects.
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Patient with Essential Hypertension and High Pulse Pressure
Patient with Essential Hypertension and Diastolic Dysfunction
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