(1)
Hypertension Research Center (CIRIAPA), University of Naples Federico II, Naples, Italy
6.1 Clinical Case Presentation
A 68-year-old, Caucasian male was admitted to the outpatient clinic for recent shortness of breath. He referred having experienced increased shortness of breath and fatigue over the last 5 months and, since then, having reduced his level of physical activity. He also reports muscle pain in the calves of both legs, mostly occurring when he increases the speed of walk and disappearing with rest.
He has history of systemic sclerosis, essential hypertension, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. He was diagnosed with systemic sclerosis 10 years before.
Hypertension was diagnosed 8 years before and treated with amlodipine 5 mg.
Atrial fibrillation was diagnosed approximately 2 years before, when he underwent direct current (DC) shock to restore sinus rhythm. One year before, the patient had recurrent atrial fibrillation and started to assume bisoprolol 2.5 mg daily and apixaban 2.5 mg twice daily.
COPD was diagnosed 15 years before and treated with oxygen therapy.
He reported to assume the following medications: bisoprolol 2.5 mg, apixaban 2.5 mg twice a day, amlodipine 5 mg daily, furosemide 25 mg daily, metilprednisolon 4 mg daily, tiotropium 1 puff daily, fluticasone 2 puff daily and oxygen therapy.
Family History
He has paternal history of hypertension, myocardial infarction and diabetes and maternal history of systemic lupus and stroke. He also has one sibling with hypertension and hypercholesterolaemia.
Clinical History
Former smoker (more 20 cigarettes daily) for more than 40 years, non-smoker for 1 year at presentation to the clinic. He also has one additional modifiable cardiovascular risk factor: sedentary life habits. There are no further cardiovascular risk factors, associated clinical conditions or non-cardiovascular diseases.
Physical Examination
Weight: 65 kg.
Height: 165 cm.
Body mass index (BMI): 23.88 kg/m2.
Waist circumference: 90 cm.
Respiration: diminished vesicular sounds.
Heart sounds: S1–S2 is diminished. S3 is heard at the apex. A holosystolic murmur (IV/VI Levine) is heard best at the left lower sternal border. In addition, the murmur intensity increases with inspiration.
There are mild oedema of both lower extremities and hepatojugular reflux (an increase in the JVP more than 4 cm).
Examination of the abdomen: the anterior wall is round and soft. The liver edge is palpable. The spleen is not palpable.
Resting pulse: irregular rhythm with a normal heart rate of 70 beats/min.
Carotid arteries: no murmurs.
Femoral and foot arteries: diminished peripheral pulses.
Haematological Profile
Haemoglobin: 11.3 g/dL
Haematocrit: 37 %
Fasting plasma glucose: 87 mg/dL
Lipid profile: total cholesterol (TOT-C): 128 mg/dL; low-density lipoprotein cholesterol (LDL-C): 75 mg/dL; high-density lipoprotein cholesterol (HDL-C): 44 mg/dL; triglycerides (TG): 60 mg/dL
Electrolytes: sodium, 140 mEq/L; potassium, 4.8 mEq/L
Serum uric acid: 6.2 mg/dL
Renal function: urea, 49 mg/dL; creatinine, 1.17 mg/dL; estimated glomerular filtration rate (eGFR) (MDRD), 66 mL/min/1.73 m2
VES: 43 mm
PCR 1.2 mg/dL
IgA, IgG, IgM: normal
C3: 82 (normal range 90–207)
C4: 14.4 (normal range 17–52)
Urine analysis (dipstick): normal
Normal liver function tests
Normal thyroid function tests
Blood Pressure Profile
Home BP (average): 130/80 mmHg
Sitting BP: 123/76 mmHg (right arm); 118/71 mmHg (left arm)
Standing BP: 122/77 mmHg at 1 min
12-Lead ECG
Atrial fibrillation with a heart rate of 70 bpm (Fig. 6.1).
Figure 6.1
12-lead ECG at the first available visit
Chest X-Ray
Chest X-ray showed (Fig. 6.2):
Abnormally large amounts of air spaces in the lung
A flattened diaphragm
An enlargement of the diameter of the right descending branch of the pulmonary artery (sign of pulmonary arterial hypertension—arrow)
Paucity of vascular markings in the lung (arterial deficiency)
Figure 6.2
Chest X-ray at the first available visit
Echocardiography
The echocardiography showed severe right ventricular dilatation with global hypokinesia (TAPSE 10 mm), right atrial enlargement (RA area 3.7 cm2), severe tricuspid regurgitation, severe pulmonary arterial hypertension (PAPs 75 mmHg; inferior vena cava 38 mm), concentric left ventricular rearrangement (LV mass indexed 45.2 g/m2.7, relative wall thickness 0.44) with normal chamber dimension (LV end-diastolic diameter 45 mm), impaired left ventricular relaxation (E/A ratio < 1) at both conventional and tissue Doppler evaluations and normal ejection fraction (LV ejection fraction 62%) (Figs. 6.3, 6.4 and 6.5).
Figure 6.3
Echocardiography at the first visit
Figure 6.4
Inferior vena cava
Figure 6.5
Tricuspid Doppler
Vascular Ultrasound
Carotid vascular ultrasound showed atherosclerotic plaques at carotid bulb (max. 1.5 mm) and the internal carotid artery (max. 1.7 mm), bilateral.
Lower Limbs
Thrombotic occlusion of the superficial femoral artery bilaterally, with deep femoral artery rehabilitation.
Diagnosis
Severe pulmonary hypertension in patient with systemic sclerosis, COPD and atrial fibrillation in patient with arterial hypertension, left ventricular hypertrophy with severe right ventricular hypokinesia, carotid plaque, thrombotic occlusion of the superficial femoral artery bilaterally.
Treatment Evaluation
Start canrenone 25 mg three times a week.
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