(1)
Hypertension Research Center (CIRIAPA), University of Naples Federico II, Naples, Italy
3.1 Clinical Case Presentation
An 82-year-old female was admitted with shortness of breath and exertional dyspnoea. She reported partial relief using more than one pillow under the head in bed during sleep. She also referred history of essential hypertension, hypercholesterolaemia and atrial fibrillation.
Hypertension and hypercholesterolaemia had been diagnosed 13 years before and, at that moment, were, respectively, treated with amlodipine 10 mg and atorvastatin 20 mg/day. Atrial fibrillation had been diagnosed 2 years before and was treated with both bisoprolol 2.5 mg and rivaroxaban 20 mg daily.
She referred several admissions to the emergency department having occurred during the two previous months for shortness of breath at rest. For these reasons, her referring physician additionally prescribed her furosemide 25 mg three times a week, which slightly improved her functional status.
Family History
She has paternal history of stroke and maternal history of hypercholesterolaemia. She also has one sibling with hypertension and myocardial infarction.
Clinical History
She never smoked. She has two additional modifiable cardiovascular risk factors: sedentary life habits and obesity.
Physical Examination
Weight: 70 kg.
Height: 152 cm.
Body mass index (BMI): 30.3 kg/m2.
Waist circumference: 107 cm.
Respiration: late inspiratory crackles are heard bilaterally in the lower lung field.
Heart exam: S3 is heard at the apex. A holosystolic murmur (III/VI Levine) is heard best at the apex.
Physical examination reveals severe oedema of both lower extremities (Fig. 1.1).
Resting pulse: regular rhythm with normal heart rate (76 beats/min).
Carotid arteries: no murmurs.
Femoral and foot arteries: normal peripheral pulses.
Haematological Profile
Haemoglobin: 11.9 g/dL
Haematocrit: 38%
Fasting plasma glucose: 87 mg/dL
NT pro BNP: 978 pg/mL
Lipid profile: total cholesterol (TOT-C), 245 mg/dL; low-density lipoprotein cholesterol (LDL-C), 155 mg/dL; high-density lipoprotein cholesterol (HDL-C), 55 mg/dL; triglycerides (TG), 160 mg/dL
Electrolytes: sodium, 140 mEq/L; potassium, 4 mEq/L
Serum uric acid: 6.5 mg/dL
Renal function: urea, 40 mg/dL; creatinine, 0.9 mg/dL; estimated glomerular filtration rate (eGFR) (MDRD), 59.74 mL/min/1.73 m2
Urine analysis (dipstick): normal
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 110/60 mmHg
Sitting BP: 115/65 mmHg (right arm); 110/60 mmHg (left arm)
Standing BP: 120/60 mmHg at 1 min
12 Lead ECG
Atrial fibrillation with normal heart rate (70 bpm) (Fig. 3.1).
Figure 3.1
12 lead ECG at the first available visit
Chest X-Ray
Positive for interstitial oedema.
Echo
Echocardiography showed a concentric hypertrophy (LVMid, 62.7 g/m2.7; RWT, 0.5), atrial enlargement (LAVi 50.35 cm3/m2) with normal ejection fraction of 55%. Mild mitral and aortic regurgitations. Severe increase in pulmonary systolic blood pressure and increased filling pressures (E/E’ ratio 24) (Figs. 3.2 and 3.3).
Figure 3.2
Echocardiography at the first available visit (Panel a: 4 chamber; panel b: doppler study of mitral valve)
Figure 3.3
Echocardiography at the first available visit (Panel a: TDI [tissue doppler imaging] at septum level; panel b: TDI at lateral wall)
Q1: Which is the correct diagnosis?
- 1.
Essential hypertension without heart failure
- 2.
Essential hypertension whit systolic heart failure
- 3.
Essential hypertension with systolic heart failure and atrial fibrillation
- 4.
Essential hypertension with diastolic heart failure and atrial fibrillation
Diagnosis
Diastolic heart failure NYHA (New York Health Association) classification II in patient with essential hypertension, hypercholesterolaemia and atrial fibrillation. Additional modifiable cardiovascular risk factors (sedentary habits and visceral obesity).
Treatment Evaluation
Start ACE (angiotensin-converting enzyme) inhibitors: ramipril 10 mg daily.
Stop amlodipine 10 mg.
Start furosemide 25 mg daily.
Prescriptions
Periodical BP evaluation at home according to recommendations from guidelines
Regular physical activity and low-salt intake
Periodical evaluation for renal function
3.2 Follow-Up (Visit 1) at 6 Weeks
At follow-up visit the patient presents a deterioration of her functional status, having the dyspnoea worsened and being it accompanied by a dry, 3-week-lasting, persistent cough. The cough interferes with her ability to sleep at night and with routine activities during the day. No recent chest infection can explain the cough. She also reports poor adherence to prescribed medications. No significant changes of renal function have been recorded.
Physical Examination
