CASE PRESENTATION: Uncontrolled

1
CASE PRESENTATIONUncontrolled Essential
Hypertension, Stage II

• Jasjot Garcha MD
• PGY1, Internal Medicine
• Allan B. Schwartz, MD
• Professor of Medicine
• Division of Nephrology and Hypertension
• Director of CME, Department of Medicine
• Drexel University College of Medicine

2
Chief Complaint and HPI

• A 55 year old Caucasian male,
• history of hypertension for 30 years with poor
  follow up and irregular BP monitoring. Pt. was
  diagnosed of hypertension at the age of 25 years
  (160/96). He was treated originally with Serapes
  (Reserpine Hydralazine HCTZ) followed by
  Propanolol and Triamterene/HCTZ.
• presents at the nephrology clinic with a nose
  bleed and accompanied blood pressure of 180/110mm
  Hg.
• ROS was within normal limits except for knee pain
  which is relieved by Ibuprofen.

3
Past medical and surgical history

• Paroxysmal atrial tachycardia with hypokalemia(
  2.9 mEq/L) in his mid 20s.

4
Family history

• Father Died at 75 of Acute M.I. Hypertensive
  since his 20s with history of paroxysmal atrial
  tachycardia and paroxysmal atrial flutter.
• Paternal Grand Father died at 81 of CHF , CAD

5
Social history

• Physician
• Runs 4 miles per day
• Non smoker
• occasional alcohol consumption

6
Medications

• Felodipine 2.5mg QD
• Metoprolol 50mg BID
• Triamterene/HCTZ (37.5/25) 1 tablet daily
• Ibuprofen 600 mg PRN

7
Physical exam

• BP160/90 mm Hg P 50/min
• Fundi show diffused arteriolar narrowing and AV
  nicking.
• Heart regular, No m/g
• Lungs clear
• Pulses intact

8
Labs and further studies(11/1997)

• BUN/Cr30/1.9
• TG 323, Total Chol 232, LDL 136, HDL 31
• No proteinuria
• CrCl(Cockcroft Gault) 45 ml/min
• ECG normal
• Echocardiogram no LVH
• Renal scan 8.6cm right 9.3cm left
• Renal blood flow scan no evidence of RAS
• Serum Cortisol and Aldosterone levels Normal

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Further plan

• Low salt diet
• Maintain exercise program
• Start Quinapril 5mg QD
• Conitinue Metoprolol 50 mg BID Triamterene/HCTZ
  37.5/25 mg QD
• 24 hr. urine for VMA, catecholamines,
  metanephrines
• Consider statin

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Questions

• What is the likely etiology?
• How do genetics and the patient risk factors
  relate?
• How many anti-hypertensives drugs will this
  patient require?
• Would this patient have required a statin
  irrespective of his lipid profile?
• What are the endothelial protective effects of
  statins in the hypertensive patients?

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Follow up over the next 5 years
Date BP SCr
7/1998 138/84 1.9
11/1998 150/80 2.5
3/1999 150/84 2.2
12/1999 138/85 2.1
2/2000 130/85 1.9
7/2000 110/80 2.2
12/2000 136/82 2.0
4/2001 130/80 1.7
11/2001 128/70 2.1
7/2002 130/78 1.9
11/2003 124/88 1.8

• Negative24 hr Urine VMA, metanephrines and
  catecholamines
• Started Amlodipine 5mg QD(7/1998) but D/C as
  patient felt dizzy after running (BP 128/70)
• Started Atorvastatin 10mg QD(8/1998) and ASA 81
  mg QD(8/1999)
• Increase Quinapril to 20mg BID (11/97-8/98)

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Most Recent Labs and BP(02/2004)

• BP 160/90
• BUN/Cr 29/1.8
• TG 178, Total Chol 172, LDL 100, HDL 36
• No proteinuria
• CrCl (Cockcroft Gault) 47ml/min
• ECG normal
• Echocardiogram no LVH

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Current medications

• Quinapril 20mg BID
• Metoprolol 50 mg BID
• Triamterene/HCTZ 37.5/25 mg QD
• Atrovastatin 10mg QD
• ASA 81 mg QD

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Questions

• What are the reasons for the loss of BP control
  at this stage?