(1)
Hypertension Research Center (CIRIAPA), University of Naples Federico II, Naples, Italy
4.1 Clinical Case Presentation
A 74-year-old Caucasian male was admitted to the outpatient clinic for recent shortness of breath.
Over the previous 5 months, he reported increased shortness of breath and fatigue after a steady 10 min walk at the park. Since then, he reduced his level of physical activity. He is used to sleep with two, sometimes three, pillows. He did not report having experienced chest pain, leg pain or fainting spells.
He was diagnosed with heart failure 1 year before (LVEF 38%) and, after a myocardial infarction, treated with a coronary-artery bypass. He also referred history of essential hypertension and diabetes treated with oral medications.
His therapy included:
Ramipril 2.5 mg
Atenolol 50 mg
Furosemide 20 mg (three times a week)
Acetylsalicylic acid (ASA) 100 mg
Atorvastatin 20 mg
Metformin 500 mg (three times a day)
Family History
He has paternal history of hypertension and myocardial infarction and maternal history of diabetes and hypercholesterolaemia. He also has one sibling with hypertension and stroke.
Clinical History
Former smoker (about 10–20 cigarettes daily) for more than 40 years, non-smoker for 1 year at presentation to the clinic. He also has two additional modifiable cardiovascular risk factors: sedentary life habits and overweight (visceral obesity). There are no further cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.
Physical Examination
Weight: 89 kg.
Height: 171 cm.
Body mass index (BMI): 30.44 kg/m2.
Waist circumference: 121 cm.
Respiration: inspiratory crackles are heard bilaterally in the lower lung field.
Heart exam: S1–S2 are diminished. S3 is heard at the apex. A grade 3/6 holosystolic murmur is heard best at the apex; it radiated to the left axilla.
There is oedema of both lower extremities.
Examination of the abdomen: The anterior wall is round and soft. The liver edge is palpable. The spleen is not palpable.
Resting pulse: regular rhythm with normal heart rate of 67 beats/min.
Carotid arteries: no murmurs.
Femoral and foot arteries: diminished peripheral pulses.
Haematological Profile
Haemoglobin: 14.4 g/dL
Haematocrit: 45%
Fasting plasma glucose: 117 mg/dL
NT pro BNP: 897 pg/mL
Lipid profile: total cholesterol (TOT-C), 184 mg/dL; low-density lipoprotein cholesterol (LDL-C), 115 mg/dL; high-density lipoprotein cholesterol (HDL-C), 39 mg/dL; triglycerides (TG), 147 mg/dL
Electrolytes: sodium, 146 mEq/L; potassium, 4.2 mEq/L
Serum uric acid: 4.1 mg/dL
Renal function: urea, 24 mg/dL; creatinine, 0.8 mg/dL; estimated glomerular filtration rate (eGFR) (MDRD), 88 mL/min/1.73 m2
Urine analysis (dipstick): normal
Albuminuria: 12.2 mg/24 h
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 145/90 mmHg
Sitting BP: 155/95 mmHg (right arm); 150/93 mmHg (left arm)
Standing BP: 152/98 mmHg at 1 min
Lead Electrocardiogram
Sinus rhythm with normal heart rate (63 bpm) with anterolateral Q waves (signs of previous infarction). Normal atrioventricular and intraventricular conduction.
Chest X-Ray
There is moderate cardiac enlargement. Pulmonary vascular congestion and mild pulmonary oedema are present: increased haziness and decreased radiolucency of the lung parenchyma bilaterally (Fig. 4.1).
Figure 4.1
Chest X-ray at the first visit
Echocardiography
The echocardiogram showed a dilated heart; in particular, the following diameters have been recorded: left ventricular end-diastolic dimension 61 cm, left ventricular end-systolic dimension 50 cm. In addition, anterior and septal hypokinesis associated with apical dilatation and reduced left ventricular ejection fraction (28%) as a marker of previous anterior infarction were found. Finally, mild mitral regurgitation was detected (Fig. 4.2).
Figure 4.2
Echocardiography at the first visit (Panel a: 4 chamber; panel b: long axis)
Vascular Ultrasound
Carotid: intima-media thickness at both carotid levels (at right, atherosclerotic plaque extending towards the internal carotid artery) with evidence of atherosclerotic plaques (Fig. 4.3).
Figure 4.3
Carotid ultrasound at the first visit
Q1: Which is the correct diagnosis?
- 1.
Essential hypertension without heart failure.
- 2.
Systolic heart failure New York Health Association (NYHA) class III in patient with ischaemic dilated cardiomyopathy, essential hypertension and non-insulin-dependent diabetes.
- 3.
Essential hypertension with systolic heart failure and atrial fibrillation.
- 4.
Essential hypertension with diastolic heart failure and atrial fibrillation.
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