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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

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
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
physical examination and laboratory tests 1995
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
examinations and tests continued
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
treatment 1995
Treatment (1995)
  • ACE-Inhibitor
  • Diuretic
  • ASA 75–100 mg
  • Statin
1995 2006
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
january 2012
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
physical examination and laboratory tests january 2012
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
examinations and tests continued january 2012
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

strategy
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
march 2012
March 2012
  • Blood pressure still sub-optimal(office 156/94 mmHg)
    • therapy modified to triple combination
  • Aspirin added
treatment june 2012
Treatment (June 2012)
  • ARB + diuretic + calcium channel blocker (as FDC)
  • ASA 75–100 mg
  • Statin (high dose)
  • Metformin
  • CPAP treatment
last visit june 2012
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
summary
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