Patient with Hypertension and Left Atrial Enlargement




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

 




1.1 Clinical Case Presentation


A 71-year-old Caucasian male was admitted to the outpatient clinic for hypertension and palpitations. He referred history of essential hypertension persisting for more than 4 years, treated with nifedipine GITS 30 mg once a day. The average values of home blood pressure were 130/80 mmHg.


Family History


Both parents and one brother (47 years old) have history of arterial hypertension.


Clinical History


Former smoker (about 10–20 cigarettes daily) for more than 30 years until the age of 55, he does not present additional cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.


Physical Examination






  • Weight: 79 kg


  • Height: 160 cm


  • Body mass index (BMI): 30.8 kg/m2


  • Waist circumference: 108 cm


  • Respiration: normal


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


  • Resting pulse: regular rhythm with normal heart rate (60 beats/min) (Fig. 1.1)


  • Carotid arteries: no murmurs


  • Femoral and foot arteries: palpable


A430940_1_En_1_Fig1_HTML.gif


Figure 1.1
Electrocardiogram at the first available visit


Haematological Profile






  • Haemoglobin: 14.5 g/dL


  • Haematocrit: 45%


  • Fasting plasma glucose: 102 mg/dL


  • Lipid profile: total cholesterol (TOT-C), 131 mg/dL; low-density lipoprotein cholesterol (LDL-C), 70 mg/dL; high-density lipoprotein cholesterol (HDL-C), 39 mg/dL; triglycerides (TG), 110 mg/dL


  • Electrolytes: sodium, 144 mEq/L; potassium, 4.2 mEq/L


  • Serum uric acid: 5.9 mg/dL


  • Renal function: urea, 39 mg/dL; creatinine, 0.9 mg/dL; creatinine clearance (Cockroft-Gault), 84.6 mL/min; estimated glomerular filtration rate (eGFR) (MDRD), 99 mL/min/1.73 m2


  • Urine analysis (dipstick): normal


  • Albuminuria: 11.9 mg/24 h


  • Liver function tests: normal


  • Thyroid function tests: normal


Blood Pressure Profile






  • Home BP (average): 125/75 mmHg


  • Sitting BP: 130/85 mmHg (right arm); 130/80 mmHg (left arm)


  • Standing BP: 125/85 mmHg at 1 min


12-Lead Electrocardiogram


Sinus rhythm with normal heart rate (57 bpm), normal atrioventricular and intraventricular conduction and normal ST segment without signs of LVH (Fig. 1.1).


Vascular Ultrasound


Both common carotids present an increase of the intima-media thickness (right, 1.3 mm, left, 1.0 mm) without evidence of significant atherosclerotic plaques.


Echocardiogram


Eccentric LV hypertrophy (LV mass indexed 56.2 g/m2.7, relative wall thickness 0.33) with normal chamber dimension (LV end-diastolic diameter 54 mm), impaired LV relaxation (E/A ratio = 0.71), normal ejection fraction (LV ejection fraction 62%). Normal dimension of aortic root and left atrial dilatation (49.45 cm3/m2). Right ventricle with normal dimension and function. Pericardium without relevant abnormalities (Fig. 1.2).

A430940_1_En_1_Fig2_HTML.gif


Figure 1.2
Echocardiogram at the first available visit (Panel a: 4 chamber; panel b: 2 chamber)

Mitral (+) and aortic (+) regurgitations at Doppler ultrasound examination.


Current Treatment


Nifedipine GITS 30 mg once a day.


Diagnosis


Essential hypertension with satisfactory BP control. Cardiac organ damage (concentric LV hypertrophy) and impaired LV relaxation. Additional cardiovascular risk factors (visceral obesity).


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




  1. 1.


    Low

     

  2. 2.


    Moderate

     

  3. 3.


    High

     

  4. 4.


    Very high

     


Global Cardiovascular Risk Stratification


Echocardiography reveals signs of cardiac organ damage (eccentric LV hypertrophy) which, per se, is able to modify the individual global cardiovascular risk profile. On the basis of the echocardiographic assessment, this patient presents a high cardiovascular risk profile, according to the 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) global cardiovascular risk stratification [1].


Treatment Evaluation






  • Stop nifedipine


  • Start telmisartan 80 mg once a day


Prescriptions






  • Periodical BP evaluation at home according to recommendations from guidelines


  • Regular physical activity and low caloric intake


  • ECG Holter monitoring


1.2 Follow-Up (Visit 1) at 6 Weeks


At follow-up visit, the patient is still symptomatic for dyspnoea. He now practices moderate physical activity two times per week with beneficial effects (weight loss). He also reports good adherence to prescribed medications without adverse reactions or drug-related side effects, but still has palpitations.


Physical Examination






  • Weight: 76 kg


  • Resting pulse: irregular rhythm with normal heart rate, 68 beats/min


  • Respiration: signs of fluid overload in the lower lung field


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


Blood Pressure Profile






  • Home BP (average): 120/75 mmHg


  • Sitting BP: 125/85 mmHg


  • Standing BP: 130/80 mmHg

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

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