Case presentation

1
Case presentation

• A 69 year old diabetic female is referred because
  her 25-year hypertension is widely fluctuating.
  Lowest figure was 135/50 7m. Ago.
• Known to have an old inferior myocardial
  infarction.
• Now severe headache, frequent nocturnal angina,
  skipping palpitation, and shortness of breath.
• Rx. Atenolol (50), Ramipril (5), Bumetanide (1),
  Aspirin (150), Isosorbide mononitrate (20),
  Mixtard human insulin 20 iu/D and Metformin (850)
• She gained weight since you last saw her 4 y.
  earlier. Dx of hypothyroidism was made. She takes
  Levo-thyroxin 50 uG/D

2
Examination

• Pulse 62/m. Regular
• BP 266/96 sitting stand. (Rt. arm)
• JVP N. Clear lungs.
• LVH. S4. Aortic ejection murmur. 2/6
• Intact peripheral pulses.
• No abdominal or neck bruits.
• Negative neurologic examination.
• Fundi KW2.

3
Work-up

• ECG remote IWMI, sinus bradycardia.
• CBC N. RBS 190. Creatinine 1.5
• Cholesterol 204 UA 4.8 Na 143 K 3.6
• GOT 62 GPT 34
• TSH 6.2 uIU/ml.(N 0.1-5)
• Urine protein Granular casts Glucose
• Echocardiography no regional wall motion
  abnormality. The LVEF is 56 The aortic cusps are
  thick, with a peak systolic gradient of 34 mmHg.
• What will you do next.

4
Progress

• She is not willing to be admitted to hospital.
  The daughter says she can measure her BP at home.
  You check and find that she really can.
• The patient is convinced (with difficulty) to
  move into her daughters home.
• You add to her treatment 20 mg of long-acting
  Nifedipine after supper, and arrange an
  appointment with her endocrinologist.
• Is this a typical sick old lady?
• Why is her hypertension so stubborn?
• What was the cause of her shortness of breath?

5
Progress

• Three hours later her daughter calls to tell you
  that the BP has dropped to 116/43, using a well
  calibrated electronic device.
• The daughter is in panic, but the old lady feels
  fine.
• Are you worried? Why?
• What should you recommend now? She still refuses
  to go to hospital.

6
Progress

• You advice rest, fluids, withholding the morning
  dose of bumetanide and follow up next evening at
  your office.
• The next morning, the daughter calls again. Now
  The BP 186/80. You resume the treatment without
  long-acting nifedipine.
• That evening the BP is 192/90.
• Do you think you will discover a cause for
  secondary hypertension?

7
Further work-up

• Abdominal ultrasonography grade 1 parenchymal
  renal disease
• Renal arterial duplex no abnormality
• 24h urinary metanephrin normetanephrin Normal
• What now?

8
What to do next

• Add longer acting calcium antagonist. Wide BP
  fluctuations are common in old age. This is due
  to decreased carotid sinus sensitivity and in
  this case possibly also autonomic neuropathy.
• Ambulatory BP recording to monitor BP control.
• Tighter control of diabetes.
• Adjustment of thyroid status.