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HTN, obese male patient, elevated Heart Rate, Insulin resistance, OSA and SO
41 years old

CASE PRESENTATION

  • The patient is now 41-years-old, obese , and is admitted at the hospital due to shortness of breath and arterial hypertension

    He was diagnosed with arterial hypertension when he was 22 years

    In the ward, he presented with intense dyspnea and arterial hypertension with BP levels of 190 /110 mm Hg

    His adherence to treatment was irregular

    He started to present episodes of intense snoring during sleep and a sensation of suffocation upon awakening

    The patient admits of being obese and that his weight has progressively increased since the age of 28 years

  • Physical examination
    weight=112 kg, height
    body mass index was 31
    pulse of 101 bpm, BP 200/110 mm Hg
  • Pulmonary assessment found
    crackles auscultation did not disclose any extra heart sounds abdomen was large; presented an "abdominal apron", without visceromegaly; slight lower-limb edema and decreased pulse in the lower limbs
  • Chest X-ray showed
    normal heart size
  • Electrocardiogram (ECG) (March 7, 2001) showed
    sinus rhythm, heart rate of 99 bpm, PR interval of 172 ms, QRS duration of 96 ms, QT interval of 372 ms, a QRS axis shifted (-300), initial notch with QS III wave and aVF, nonprogressive R wave from V1 to V3 and electrical left ventricular hypertrophy
  • Echocardiogram showed
    septum and posterior wall thickness of 14 mm, aortic diameter of 32 mm, left atrial diameter of 52 mm, left ventricular (LV) diastolic diameter of 47 mm, with ejection fraction of 53%, due to accentuated diffuse hypokinesis

QUESTIONS

+ What according to you are the causes of secondary HTN in middle aged patients?
  • Primary aldosteronism
  • Obstructive sleep apnea
  • Cushing’s syndrome
  • Coarctation of the aorta
  • Phaeochromocytoma
  • Monogenic disorders
  • Renal parenchymal disease
  • Atherosclerotic renovascular disease
  • Thyroid disease
SHOW ANSWER
Primary aldosteronism
Obstructive sleep apnea
Cushing’s syndrome
Phaeochromocytoma
Renal parenchymal disease
Atherosclerotic renovascular disease


Common causes of secondary hypertension
+ What do you think should be the diagnosis of this case?
  • Primary hypertension
  • Secondary hypertension
SHOW ANSWER
Secondary hypertension

Incidence and typical causes of secondary hypertension according to age

Obesity activates the sympathetic nervous system

Obesity is associated with increased sympathetic nerve activity

Obstructive sleep apnea and hypertension

Obstructive sleep apnea and obesity

Obstructive sleep apnea and obesity - 2
+ What should be the BP threshold for treatment in such a case?
  • SBP≥140, DBP≥90
  • SBP≥90, DBP≥90
  • SBP≥140, DBP=90
SHOW ANSWER
SBP≥140, DBP≥90

Office BP treatment target range Office BP treatment target range - 2