Patient with Essential Hypertension and Proteinuria




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

 




4.1 Clinical Case Presentation


A 67-year-old, Caucasian female, teaching professor at the University of Ancient Literature, presented to the Outpatient Clinic for uncontrolled hypertension.

She has history of essential hypertension by about 20 years, treated with ACE inhibitor (ramipril 10 mg), beta-blockers and thiazide diuretic (nebivolol 5/25 mg) with satisfactory BP control.

By about 3 months, she reported uncontrolled BP levels measured at work. For this reason, her referring physician prescribed a calcium-channel blocker (lacidipine 6 mg) in addition to current pharmacological therapy.


Family History


He has maternal history of hypertension and diabetes and paternal history of coronary artery disease and diabetes.


Clinical History


She is a smoker (about 20 cigarettes daily) by more than 20 years. She is affected by dyslipidaemia, treated with combination therapy of simvastatin/ezetimibe 20/10 mg daily. She also reported intense working activity and mental stress with limited physical activity. About 5 years ago, she started metformin 1000 mg for impaired fasting glucose. She has no other additional cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.


Physical Examination






  • Weight: 77 kg


  • Height: 175 cm


  • Body mass index (BMI): 24.1 kg/m2


  • Waist circumference: 97 cm


  • Respiration: normal


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


  • Resting pulse: regular rhythm with normal heart rate (60 beats/min)


  • Carotid arteries: no murmurs


  • Femoral and foot arteries: palpable


Haematological Profile






  • Haemoglobin: 15.7 g/dL


  • Haematocrit: 54.5 %


  • Fasting plasma glucose: 73 mg/dL


  • Fasting lipids: total cholesterol (TOT-C), 196 mg/dl; low-density lipoprotein cholesterol (LDL-C), 140 mg/dl; high-density lipoprotein cholesterol (HDL-C), 28 mg/dl; triglycerides (TG) 140 mg/dl


  • Electrolytes: sodium, 141 mEq/L; potassium, 4.4 mEq/L


  • Serum uric acid: 5.8 mg/dL


  • Renal function: urea, 28 mg/dl; creatinine 1.08 mg/dL; creatinine clearance (Cockcroft–Gault), 61 ml/mn; estimated glomerular filtration rate (eGFR) (MDRD), 54 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): 140/100 mmHg


  • Sitting BP: 155/108 mmHg (right arm); 152/106 mmHg (left arm)


  • Standing BP: 156/105 mmHg at 1 min


  • 24-h BP: 151/103 mmHg; HR: 75 bpm


  • Daytime BP: 153/106 mmHg; HR: 78 bpm


  • Night-time BP: 140/92 mmHg; HR: 62 bpm

The 24-h ambulatory blood pressure profile is illustrated in Fig. 4.1.

A335263_1_En_4_Fig1_HTML.gif


Figure 4.1
24-h ambulatory blood pressure profile at first visit


12-Lead Electrocardiogram


Sinus rhythm with normal heart rate (69 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities without signs of LVH (aVL 0.7 mV; Sokolow–Lyon, 2.2 mV; Cornell voltage 1.2 mV; Cornell product 99.6 mV*ms) (Fig. 4.2)

A335263_1_En_4_Fig2_HTML.gif


Figure 4.2
12-lead electrocardiogram at first visit: sinus rhythm with normal heart rate (69 bpm), normal atrioventricular and intraventricular conduction, ST-segment abnormalities without signs of LVH. Peripheral (a) and precordial (b) leads


Echocardiogram with Doppler Ultrasound


Concentric LV remodelling (LV mass indexed 93 g/m2; relative wall thickness: 0.47) with normal chamber dimension (LV end-diastolic diameter 44 mm) (Fig. 4.3a), impaired LV relaxation (E/A ratio 1.02) (Fig. 4.3b) at conventional Doppler evaluation and normal ejection fraction (LV ejection fraction 60 %). Normal dimensions of aortic root and left atrium. Right ventricle with normal dimension and function. Pericardium without relevant abnormalities

A335263_1_En_4_Fig3_HTML.gif


Figure 4.3
Echocardiogram with Doppler ultrasound at first visit: concentric LV remodelling with normal chamber dimension (a), impaired LV relaxation (b) at conventional 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

Mitral (+) regurgitation at Doppler ultrasound examination


Vascular Ultrasound






  • Carotid: intima–media thickness at both carotid levels (right: 1.1 mm; left: 1.2 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. 4.4a) and left (Fig. 4.4b) renal arteries. Normal dimension and structure of the abdominal aorta

    A335263_1_En_4_Fig4_HTML.gif


    Figure 4.4
    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. Normal dimension and structure of the abdominal aorta


Current Treatment


Ramipril 10 mg h 8:00; nebivolol 5/25 mg h 8:00; lacidipine 6 mg h 20:00; metformin 500 mg h 12:00 and h 20:00; aspirin 100 mg h 12:00; simvastatin/ezetimibe 20/10 mg h 22:00


Diagnosis


Essential (stage 2) hypertension with unsatisfactory BP control on combination therapy. Smoking, dyslipidaemia, impaired glucose tolerance, sedentary life with work-related stress. Renal impairment (eGFR <60 mL/min/1.73 m2 with normal creatinine clearance). No evidence of cardiac and vascular organ damage. No other 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 high cardiovascular risk.


Which is the best therapeutic option in this patient?

Possible answers are:

1.

Add another drug class (e.g. antialdosterone agent).

 

2.

Add another drug class (e.g. loop diuretic).

 

3.

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

 

4.

Switch from ACE inhibitor to angiotensin receptor blocker.

 

5.

Switch from ACE inhibitor to direct renin inhibitor.

 


Treatment Evaluation






  • Stop ramipril 10 mg and start valsartan 80 mg h 8:00.


  • Stop lacidipine 6 mg and start amlodipine 5 mg h 20:00.


  • Maintain nebivolol 5/25 mg h 8:00, metformin 500 mg h 12:00 and h 20:00, aspirin 100 mg h 12:00 and simvastatin/ezetimibe 20/10 mg h 22:00.


Prescriptions






  • Periodical BP evaluation at home according to recommendations from guidelines.


  • Stop smoking.


  • Try to reduce work overload and physical stress.


  • Moderate physical activity.


  • 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.

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Jul 17, 2017 | Posted by in NEPHROLOGY | Comments Off on Patient with Essential Hypertension and Proteinuria

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