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Clinical Case 1

Clinical Case 1. Krzysztof Narkiewicz Medical University of Gdańsk, Gdańsk, Poland. Relevant disclosure of interest: Consultant to Daiichi Sankyo and the Menarini group. Start of case – 1995. A 38-year old man, engineer, presenting with newly diagnosed hypertension

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Clinical Case 1

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  1. Clinical Case 1 Krzysztof Narkiewicz Medical University of Gdańsk, Gdańsk, Poland Relevant disclosure of interest: Consultant to Daiichi Sankyo and the Menarini group

  2. Start of case – 1995 • A 38-year old man, engineer, presenting with newly diagnosed hypertension • High BP detected during medical exam for a new job • BP not measured for more than 10 years; his previous readings were “borderline” • The patient is asymptomatic • He smokes 15 cigarettes a day • Family history - hypertension and premature CHD deaths in both parents

  3. Physical examination and laboratory tests (1995) • BMI 27 kg/m2 • Waist 102 cm • HR 80bpm • BP 170/104 mmHg • ECG – normal, with HR 76 bpm • LDL 154 mg/dl • HDL 36 mg/dl • TG 249 mg/dl • Albuminuria 25 mg/24h • eGFR 86 ml/min

  4. Examinations and tests continued Echocardiography: • Borderline left ventricular hypertrophy with normal ejection fraction ABPM: • Mean day-time blood pressure of 151/95 mmHg with mean heart rate of 80 bpm • Average night-time blood pressure of 138/82 mmHg with mean heart rate of 61 bpm

  5. Treatment (1995) • ACE-Inhibitor • Diuretic • ASA 75–100 mg • Statin

  6. 1995–2006 • Variable BP control probably due to sub-optimal compliance (several missed visits) • Gained 10 kg, sedentary lifestyle, poor diet • Continued to smoke • Asymptomatic • Last visit December 2006

  7. January 2012 • First visit since 2006 • Difficult period (divorce, new job) • Discontinued all medications • Gained 10 more kg, lifestyle still sedentary, poor diet • Daytime somnolence, poor quality of sleep • Continues to smoke • TIA three days earlier with BP of 220/120mmHg

  8. Physical examination and laboratory tests (January 2012) • BMI 34 kg/m2 • Waist 114 cm • HR 80 bpm • BP 182/106 mmHg • ECG – LVH signs, with HR 90 bpm • LDL 164 mg/dl • HDL 34 mg/dl • TG 289 mg/dl • Fasting glycaemia 155 mg/dl • HbA1c 8.4% • Albuminuria 225 mg/24h • eGFR 49 ml/min

  9. Examinations and tests continued (January 2012) Echocardiography: • severe left ventricular hypertrophy (IVST – 14 mm) • diastolic dysfunction Carotid ultrasound: • IMT – 1.4 mm • Several plaques, but without critical stenosis PWV – 12.2 m/s

  10. Strategy • Blood pressure lowering (dual combination ARB + CCB) • Regression of target organ damage • Correction of metabolic disorders • Prevention of stroke and nephropathy • Screening for obstructive sleep apnea • Lifestyle changes

  11. March 2012 • Blood pressure still sub-optimal(office 156/94 mmHg) • therapy modified to triple combination • Aspirin added

  12. Treatment (June 2012) • ARB + diuretic + calcium channel blocker (as FDC) • ASA 75–100 mg • Statin (high dose) • Metformin • CPAP treatment

  13. Last visit (June 2012) • Perfect compliance • CPAP treatment • ABPM: • mean day-time blood pressure of 131/82 mmHg, with mean heart rate of 72 bpm • mean night-time blood pressure of 122/75 mmHg, with mean heart rate of 61 bpm

  14. Summary • Accidental detection of hypertension • Poor compliance despite good education • Totally non-compliant (untreated) for 6 years • Dramatic deterioration in health • significant organ damage • severe hypertension • Polytherapy required urgently • FDC important in reducing pill burden

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