(1)
Hypertension Research Center (CIRIAPA), University of Naples Federico II, Naples, Italy
2.1 Clinical Case Presentation
A 64-year-old, Caucasian male, was admitted to our outpatient clinic for recent uncontrolled hypertension. He reported a more than 12-year-long clinical history of essential hypertension, initially treated with a combination therapy based on ACE (angiotensin-converting enzyme) inhibitors (ramipril 5 mg) and diuretics (hydrochlorothiazide 12.5 mg).
About 5 years before, for suboptimal blood pressure (BP) control, drug therapy was titrated to ramipril 10 mg and hydrochlorothiazide 25 mg, with satisfactory BP control at home and no relevant side effects or adverse reactions.
About 3 years before, he had been reporting uncontrolled BP levels measured at home. For this reason, his referring physician prescribed amlodipine 5 mg daily in addition to the previous prescribed pharmacological therapy, with mild improvement in BP control.
The patient brought to our attention a recent (2 years earlier) echocardiogram that showed aortic root dilatation (47 mm).
In his medical history he also had diabetes and stage II chronic kidney disease.
His current medications included:
Metformin 1000 mg daily.
Acetylsalicylic acid (ASA) 100 mg daily.
Ramipril 10 mg daily.
Hydrochlorothiazide 25 mg.
Amlodipine 5 mg.
Family History
Maternal history of hypertension and paternal history of coronary artery disease. He also has one sibling with hypertension.
Clinical History
He was a previous smoker (more than 20 cigarettes daily) for more than 20 years until the age of 60 years. He has two additional modifiable cardiovascular risk factors: sedentary life habits and obesity. There are no further cardiovascular risk factors or non-cardiovascular diseases.
Physical Examination
Weight: 83 kg.
Height: 165 cm.
Body mass index (BMI): 30.4 kg/m2.
Waist circumference: 100 cm.
Respiration: clear breath sound.
Heart sounds: early diastolic murmur (II/VI Levine), best heard over the right second intercostal space, radiated towards the apex.
There was no jugular venous distension or hepatojugular reflux.
Abdomen: his abdomen was soft and non-tender.
Resting pulse: regular rhythm with heart rate of 95 beats/min.
Carotid arteries: no murmurs.
Femoral and foot arteries: symmetrical, absence of oedema.
Haematological Profile
Haemoglobin: 15 g/dL.
Haematocrit: 45%.
Fasting plasma glucose: 147 mg/dL.
Lipid profile: total cholesterol (TOT-C), 253 mg/dL; low-density lipoprotein cholesterol (LDL-C), 182 mg/dL; high-density lipoprotein cholesterol (HDL-C), 39 mg/dL; triglycerides (TG), 158 mg/dL.
Electrolytes: sodium 137.9 mEq/L; potassium 4.0 mEq/L.
Serum uric acid: 6.4 mg/dL.
Renal function: urea 50 mg/dL, creatinine 1.18 mg/dL; estimated glomerular filtration rate (eGFR) (MDRD): 66.06 mL/min/1.73 m2.
Urine analysis (dipstick): normal.
Normal liver function tests.
Normal thyroid function tests.
Blood Pressure Profile
Home BP (average): 160–165/95 mmHg.
Sitting BP: 160/90 mmHg (right arm); 155/88 mmHg (left arm).
Standing BP: 155/95 mmHg at 1 min.
12 Lead ECG
Sinus rhythm with heart rate 90 bpm, normal atrioventricular and intraventricular conduction, ST-segment abnormalities with signs of LVH (Fig. 2.1).
Figure 2.1
12-lead ECG at the first available visit
Echocardiogram
Dilatation of ascending aorta with widest diameter at the level of right pulmonary artery, measuring 41 mm. Dilated aortic root, measuring 50 mm. Descending thoracic aorta and pulmonary artery have normal diameters. Left ventricular hypertrophy (LV mass index: 64.5 g/m2.7) with eccentric pattern (relative wall thickness [RWT]: 0.36) with left ventricular thickness measured and the left ventricle is not enlarged end diastole (55 mm). There is normal wall motion of 57% and normal diastolic function. Middle aortic regurgitation (Fig. 2.2).
Figure 2.2
Echocardiogram at the first visit (Panel a: 5 chamber; panel b: M-mode long axis)
Vascular Ultrasound
Carotid: intima-media thickness at both carotid levels with evidence of atherosclerotic plaques. At right: atherosclerotic plaque of 2.3 mm extending towards the internal carotid artery (Fig. 2.3).
Figure 2.3
Carotid ultrasound at the first visit
Diagnosis
Aortic root dilatation in patient with essential hypertension, non-insulin-dependent diabetes and stage II chronic kidney disease, left ventricular hypertrophy, carotid plaque.
Additional modifiable cardiovascular risk factors (sedentary habits and visceral obesity).
Q1: 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 the 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) global cardiovascular risk stratification [1], this patient has very high cardiovascular risk (hypertension + type II diabetes mellitus + stage II chronic kidney disease + left ventricular hypertrophy + carotid plaque).
Treatment Evaluation
Start bisoprolol 2.5 mg daily.
Start atorvastatin 20 mg.
Titrate the dose of amlodipine to 10 mg.
Prescriptions
Periodical BP evaluation at home according to recommendations from guidelines.
Low-calorie and low-salt intake.
2.2 Follow-Up (Visit 1) at 6 Weeks
At follow-up visit, the patient is apparently healthy and reports good adherence to prescribed medications, although he experienced drug-related side effects.
Physical Examination
Weight: 83 kg.
Waist circumference: 100 cm.
Resting pulse: regular rhythm with heart rate of 70 beats/min.
Respiration: normal.
Heart sounds: early diastolic murmur (II/VI Levine), best heard over the right second intercostal space, radiated towards the apex. There was no jugular venous distension or hepatojugular reflux.
Femoral and foot arteries: severe oedema of both lower extremities.
Lipid Profile
TOT-C: 212 mg/dL; LDL-C:162 mg/dL; HDL-C: 37 mg/dL; TG: 165 mg/dL.
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