Patient with Essential Hypertension and Left Ventricular Enlargement




(1)
Hypertension Research Center (CIRIAPA), University of Naples Federico II, Naples, Italy

 




5.1 Clinical Case Presentation


A 51-year-old Caucasian male farmer was admitted to the outpatient clinic reporting a more than 2-year-long clinical history of uncontrolled essential hypertension and mild exertional dyspnoea. The average values of home blood pressure (BP) were 180/100 mmHg.


Family History


Both his parents (84-year-old mother and 85-year-old father) and one brother (61 years old) are hypertensive.


Clinical History


Former smoker (about 20 cigarettes per day from the age of 14 to the age of 45), heavy drinker (about 1 L/day), consuming a diet rich in saturated fats and salt. Works about 12 h/day.

Arterial hypertension has been diagnosed 2 years before. His general practitioner prescribed an antihypertensive therapy based on a fixed combination of atenolol/chlorthalidone 100/25 mg, early interrupted after 1 month for drug-related side effects (erectile dysfunction).


Comorbidities


No other comorbidities or known cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases were reported.


Physical Examination






  • Weight: 94 kg


  • Height: 173 cm


  • Body mass index (BMI): 31.4 kg/m2


  • Waist circumference: 115 cm


  • Respiration: normal


  • Heart exam: S1–S2 regular, normal and no murmurs


  • Resting pulse: regular rhythm with normal heart rate (72 beats/min)


  • Carotid arteries exam: no murmurs


  • Femoral and foot arteries: palpable


Haematological Profile






  • Haemoglobin: 15.1 g/dL


  • Haematocrit: 45.2%


  • Fasting plasma glucose: 117 mg/dL


  • Lipid profile: total cholesterol (TOT-C): 238 mg/dL; low-density lipoprotein cholesterol (LDL-C): 151.4 mg/dL; high-density lipoprotein cholesterol (HDL-C): 61 mg/dL; triglycerides (TG): 128 mg/dL


  • Serum electrolytes: sodium, 143 mEq/L; potassium, 4.8 mEq/L


  • Serum uric acid: 4.6 mg/dL


  • Renal function: urea, 50 mg/dL; creatinine, 0.98 mg/dL; creatinine clearance (Cockroft-Gault), 122.3 mL/min; estimated glomerular filtration rate (eGFR) (MDRD), 103 mL/min/1.73 m2


  • Urine analysis (dipstick): normal


  • Albuminuria: 10.8 mg/24 h


  • Normal liver function tests


  • Normal thyroid function tests


Blood Pressure Profile






  • Home BP (average): 184/115 mmHg


  • Sitting BP: 180/118 mmHg (right arm); 178/116 mmHg (left arm)


  • Standing BP: 176/120 mmHg at 1 min


12-Lead ECG


Sinus rhythm with normal heart rate (70 bpm), prolonged atrioventricular conduction (P-R interval 240 ms), criteria for left ventricular hypertrophy (R(I) + S(III) > 2.00 mV), abnormal repolarization in infero-lateral leads (Fig. 5.1).

A430940_1_En_5_Fig1_HTML.jpg


Figure 5.1
12-lead ECG at the first available visit


Echocardiogram


Eccentric left ventricular hypertrophy (LV max index 59.3 g/m2.7; relative wall thickness 0.33) with high left ventricular chamber dimension (LV end-diastolic diameter 57 mm) and volume (87.19 cm3/m2), normal ejection fraction (61%), dilated aortic root (43 mm), normal left atrium, no signs of right ventricle and/or pericardium disease. Aortic (++) regurgitation at Doppler ultrasound examination (Fig. 5.2).

A430940_1_En_5_Fig2_HTML.jpg


Figure 5.2
Echocardiogram at the first visit (Panel a: 4 chamber with color; panel b: 4 chamber without color)


Carotid Ultrasound


Both common carotids presented an increase of intima-media thickness (right, 1.0 mm; left, 0.9 mm) without evidence of significant atherosclerotic plaques.


Current Treatment


The patient does not take any medication.


Diagnosis


Essential (stage III) hypertension with hypertension-related target organ damage (left ventricular hypertrophy), hypercholesterolemia, impaired fasting glucose.


Q1: Which is the global cardiovascular risk profile in this patient?

Possible answers are:


  1. 1.


    Low

     

  2. 2.


    Medium

     

  3. 3.


    High

     

  4. 4.


    Very high

     


Global Cardiovascular Risk Stratification


According to 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) global cardiovascular risk stratification [1], this patient has very high cardiovascular risk (grade 3 HTN + 1 asymptomatic organ damage).


Treatment Evaluation






  • Start olmesartan 40 mg + amlodipine 5 mg in a single pill.


  • Start atorvastatin 20 mg.


Prescriptions


Periodical BP evaluation at home according to recommendations from current guidelines

Regular physical activity and low-calorie and low-salt intake


5.2 Follow-Up (Visit 1) After 6 Weeks


At follow-up visit the patient is in good clinical condition. He is regularly practising physical activity and following a low-calorie diet. Mean values of BP at home are normal.

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  4. Patient with Hypertension and Left Atrial Enlargement

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Oct 14, 2017 | Posted by in CARDIOLOGY | Comments Off on Patient with Essential Hypertension and Left Ventricular Enlargement

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