Practical Case Studies in Hypertension Management Series editor: Giuliano Tocci Rome Italy
The aim of the book series Practical Case Studies in Hypertension Management is to provide physicians who treat hypertensive patients having different cardiovascular risk profiles with an easy-to-access tool that will enhance their clinical practice, improve average blood pressure control, and reduce the incidence of major hypertension-related complications. To achieve these ambitious goals, each volume presents and discusses a set of paradigmatic clinical cases relating to different scenarios in hypertension. These cases will serve as a basis for analyzing best practice and highlight problems in implementing the recommendations contained in international guidelines regarding diagnosis and treatment.while the available guidelines have contributed significantly in improving the diagnostic process, cardiovascular risk stratification, and therapeutic management in patients with essential hypertension, they are of limited help to physicians in daily clinical practice when approaching individual patients with hypertension, and this is particularly true when choosing among different drug classes and molecules. By discussing exemplary clinical cases that may better represent clinical practice in a real world setting, this series will assist physicians in selecting the best diagnostic and therapeutic options. More information about this series at http://www.springer. com/series/13624
Agostino Virdis Hypertension and Comorbidities
Agostino Virdis Clinical and Experimental Medicine University of Pisa Pisa Italy ISSN 2364-6632 ISSN 2364-6640 (electronic) Practical Case Studies in Hypertension Management ISBN 978-3-319-39163-2 ISBN 978-3-319-39164-9 (ebook) DOI 10.1007/978-3-319-39164-9 Library of Congress Control Number: 2016948276 Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland
Foreword Essential hypertension is a clinical condition in which established increase of blood pressure levels may promote development and progression of major cardiovascular, cerebrovascular, and renal complications, mostly including, myocardial atrial fibrillation, infarction, stroke, and congestive heart failure, as well as metabolic abnormalities, such as obesity and diabetes. All these comorbidities heavily impact the clinical management of hypertension, being often advocated to try to explain the relatively poor rates of blood pressure control recorded in very high-risk hypertensive patients. Prompt assessment and diagnostic evaluation of these comorbidities represent a crucial aspect for the clinical management of patients with hypertension, not only in view of their influence on individual global cardiovascular risk stratification, but also in view of their potential implications for therapeutic choice among different classes and combination therapies of antihypertensive drugs. Compelling indications are, indeed, available to help physicians in choosing the most effective and better-tolerated antihypertensive drug therapy to be applied in these very high risk-hypertensive patients. Although the effective blood pressure reductions achieved throughout the implementation of the proper antihypertensive drug classes according to recommendations from international guidelines cannot impact the individual global cardiovascular risk profile in hypertensive patients with comorbidities (which is definitely very high-risk profile), it has demonstrated to reduce cardiovascular mortality and
vi Foreword hospitalization for cardiovascular causes, thus reducing the burden of hypertension-related disease. In this volume of Practical Case Studies in Hypertension Management, the clinical management of paradigmatic cases of patients with hypertension and different comorbidities will be discussed, focusing on the different diagnostic criteria currently available for identifying the presence or the absence of these associated clinical conditions, as well as on the different therapeutic options currently recommended for achieving effective and sustained blood pressure control and reduce hypertension-related morbidity and mortality. Rome, Italy Giuliano Tocci
Preface This book is structured to assist physicians in the management of hypertensive patients, with a particular emphasis on a variety of clinical conditions often associated to hypertension. The clinical cases are selected according to the very frequent clinical conditions which everyday refer to a thirdlevel Hypertension Center, thus reflecting the real world. These clinical cases raise problematics, doubts, necessity of decision making which usually are not evidenced in the medicine textbooks. They provide examples of management according to current international guidelines. The importance of associated clinical conditions deals with the necessity to choose those antihypertensive agents, alone or in a right combination each other, which are necessarily different according to what condition together with hypertension occurs. In such scenario, the clinical case includes patients with diabetes mellitus, systolic dysfunction, obesity, renal impairment, or previous stroke of myocardial infarction. By representing clinical practice in a real-life setting, these cases hopefully will help the practitioner to select the more appropriate diagnostic and treatment tools to the individual patient and the particular, thereby ameliorating the cardiovascular risk profile and prognosis. Pisa, Italy Agostino Virdis
Contents 1 Clinical Case 1: Patient with Essential Hypertension and Systolic Dysfunction........................ 1 1.1 Clinical Case Presentation.................... 1 Family History............................ 1 Clinical History........................... 2 Physical Examination...................... 2 Haematological Profile..................... 2 Blood Pressure Profile..................... 3 12-Lead Electrocardiogram................. 3 Current Treatment........................ 4 Diagnosis................................ 4 Global Cardiovascular Risk Stratification..... 6 Treatment Evaluation...................... 7 Prescriptions............................. 7 1.2 Follow-Up (Visit 1) at 2 Weeks................ 7 Physical Examination...................... 8 Blood Pressure Profile..................... 8 Current Treatment........................ 8 Haematological Profile..................... 8 or Associated Clinical Conditions.............. 9 Diagnosis................................ 9 Global Cardiovascular Risk Stratification..... 10 Treatment Evaluation...................... 10 Prescriptions............................. 11 1.3 Follow-Up (Visit 2) at 2 Months.............. 11 Physical Examination...................... 11 Blood Pressure Profile..................... 11 Haematological Profile..................... 12
x Contents Current Treatment........................ 12 or Associated Clinical Conditions............ 12 Diagnosis................................ 12 Treatment Evaluation...................... 13 Prescriptions............................. 14 1.4 Follow-Up (Visit 2) at 6 Months.............. 14 Physical Examination...................... 14 Blood Pressure Profile..................... 14 Haematological Profile..................... 15 or Associated Clinical Conditions............ 15 Current Treatment........................ 16 Treatment Evaluation...................... 17 Prescriptions............................. 17 1.5 Discussion................................. 18 References.................................... 20 2 Clinical Case 2: Patient with Essential Hypertension and Myocardial Infarction.......... 23 2.1 Clinical Case Presentation................... 23 Family History............................ 24 Clinical History........................... 24 Physical Examination...................... 24 Haematological Profile..................... 24 Blood Pressure Profile..................... 25 12 -Lead Electrocardiogram................. 27 Current Treatment........................ 28 Diagnosis................................ 28 Global Cardiovascular Risk Stratification..... 29 Treatment Evaluation...................... 29 Prescriptions............................. 30 2.2 Follow-Up (Visit 1) at 4 Weeks............... 30 Physical Examination...................... 30 Blood Pressure Profile..................... 30 Current Treatment........................ 31 or Associated Clinical Conditions............ 31
Contents xi Diagnosis................................ 32 Global Cardiovascular Risk Stratification..... 32 Treatment Evaluation...................... 33 Prescriptions............................. 33 2.3 Follow-Up (Visit 2) at 3 Months.............. 33 Physical Examination...................... 33 Blood Pressure Profile..................... 33 Current Treatment........................ 34 Diagnosis................................ 34 Treatment Evaluation...................... 34 Prescriptions............................. 34 2.4 Follow-Up (Visit 2) at 12 Months............. 34 Physical Examination...................... 35 Blood Pressure Profile..................... 35 Haematological Profile..................... 36 or Associated Clinical Conditions.............. 36 Current Treatment........................ 36 Treatment Evaluation...................... 37 Prescriptions............................. 37 2.5 Discussion................................. 37 References.................................... 40 3 Clinical Case 3: Patient with Diabetes Mellitus..... 41 3.1 Clinical Case Presentation................... 41 Family History............................ 41 Clinical History........................... 42 Physical Examination...................... 42 Haematological Profile..................... 42 Blood Pressure Profile..................... 43 12-Lead Electrocardiogram................. 43 Current Treatment........................ 43 Diagnosis................................ 44 Global Cardiovascular Risk Stratification..... 46 Treatment Evaluation...................... 47 Prescriptions............................. 47 3.2 Follow-Up (Visit 1) at 6 Weeks............... 47 Physical Examination...................... 47
xii Contents Blood Pressure Profile..................... 48 Haematological Profile..................... 48 Current Treatment........................ 48 or Associated Clinical Conditions............ 48 Diagnosis................................ 49 Global Cardiovascular Risk Stratification..... 50 Current Treatment........................ 50 Treatment Evaluation...................... 50 Prescriptions............................. 50 3.3 Follow-Up (Visit 2) at 2 Months.............. 51 Physical Examination...................... 51 Blood Pressure Profile..................... 51 Diagnosis................................ 51 Current Treatment........................ 51 Treatment Evaluation...................... 53 Prescriptions............................. 53 3.4 Follow-Up (Visit 3) at 3 Months.............. 53 Physical Examination...................... 53 Blood Pressure Profile..................... 53 Haematological Profile..................... 54 Current Treatment........................ 54 Treatment Evaluation...................... 54 Prescriptions............................. 54 3.5 Follow-Up (Visit 4) at 6 Months.............. 55 Physical Examination...................... 55 Blood Pressure Profile..................... 55 Haematological Profile..................... 55 Current Treatment........................ 55 Treatment Evaluation...................... 56 Prescriptions............................. 56 3.6 Discussion................................. 56 References.................................... 59 4 Clinical Case 4: Patient with End-Stage Renal Disease................................. 61 4.1 Clinical Case Presentation................... 61 Family History............................ 62 Clinical History........................... 62
Contents xiii Physical Examination...................... 62 Haematological Profile..................... 62 Blood Pressure Profile..................... 63 12 -Lead Electrocardiogram................. 64 Current Treatment........................ 65 Diagnosis................................ 66 Global Cardiovascular Risk Stratification..... 66 Treatment Evaluation...................... 66 Prescriptions............................. 67 4.2 Follow-Up (Visit 1) at 6 Weeks............... 67 Physical Examination...................... 67 Blood Pressure Profile..................... 67 Haematological Profile..................... 68 Current Treatment........................ 68 or Associated Clinical Conditions............ 68 Diagnosis................................ 69 Global Cardiovascular Risk Stratification..... 69 Treatment Evaluation...................... 70 Prescriptions............................. 70 4.3 Follow-Up (Visit 2) at 3 Months.............. 70 Physical Examination...................... 71 Blood Pressure Profile..................... 71 Haematological Profile..................... 71 Current Treatment........................ 71 Treatment Evaluation...................... 72 Prescriptions............................. 72 4.4 Follow-Up (Visit 3) at 1 Year................. 72 Physical Examination...................... 73 Blood Pressure Profile..................... 73 Haematological Profile..................... 73 Current Treatment........................ 74 or Associated Clinical Conditions............ 74 Treatment Evaluation...................... 75 Prescriptions............................. 75 4.5 Discussion................................. 75 References.................................... 78
xiv Contents 5 Clinical Case 5: Patient with Essential Hypertension and Congestive Heart Failure.................... 81 5.1 Clinical Case Presentation.................... 81 Family History............................ 82 Clinical History........................... 82 Physical Examination...................... 82 Haematological Profile..................... 82 Blood Pressure Profile..................... 83 12-Lead Electrocardiogram................. 83 Current Treatment........................ 84 Diagnosis................................ 84 Global Cardiovascular Risk Stratification..... 85 Treatment Evaluation...................... 87 Prescriptions............................. 87 5.2 Follow-Up (Visit 1) at 4 Weeks................ 88 Physical Examination...................... 88 Blood Pressure Profile..................... 88 Haematological Profile..................... 88 Current Treatment........................ 89 or Associated Clinical Conditions............ 89 Diagnosis................................ 90 Global Cardiovascular Risk Stratification..... 90 Treatment Evaluation...................... 91 Prescriptions............................. 91 5.3 Follow-Up (Visit 2) at 3 Months.............. 91 Physical Examination...................... 91 Blood Pressure Profile..................... 91 Haematological Profile..................... 92 Current Treatment........................ 92 Treatment Evaluation...................... 92 Prescriptions............................. 92 5.4 Follow-Up (Visit 2) at 6 Months.............. 93 Physical Examination...................... 93 Blood Pressure Profile..................... 93 Haematological Profile..................... 93 Current Treatment........................ 94
Contents xv or Associated Clinical Conditions............ 94 Echocardiogram with Doppler Ultrasound.... 94 Treatment Evaluation...................... 94 Prescriptions............................. 95 5.5 Discussion................................. 96 References.................................... 99 6 Clinical Case 6: Patient with Essential Hypertension and Atrial Fibrillation.......................... 101 6.1 Clinical Case Presentation................... 101 Family History............................ 101 Clinical History........................... 102 Physical Examination...................... 102 Haematological Profile..................... 102 Blood Pressure Profile..................... 103 12-Lead Electrocardiogram................. 104 Current Treatment........................ 105 Diagnosis................................ 106 Global Cardiovascular Risk Stratification..... 106 Treatment Evaluation...................... 106 Prescriptions............................. 107 6.2 Follow-Up (Visit 1) at 2 Weeks............... 107 Physical Examination...................... 107 Blood Pressure Profile..................... 107 Current Treatment........................ 108 Haematological Profile..................... 108 or Associated Clinical Conditions............ 108 Diagnosis................................ 109 Global Cardiovascular Risk Stratification..... 109 Treatment Evaluation...................... 110 Prescriptions............................. 110 6.3 Follow-Up (Visit 2) at 3 Months............. 110 Physical Examination...................... 111 Blood Pressure Profile..................... 111 Haematological Profile..................... 111 Current Treatment........................ 111
xvi Contents Treatment Evaluation...................... 111 Prescriptions............................. 111 6.4 Follow-Up (Visit 2) at 1 Year................ 112 Physical Examination...................... 112 Blood Pressure Profile..................... 112 Haematological Profile..................... 112 or Associated Clinical Conditions............ 113 Current Treatment........................ 113 Treatment Evaluation...................... 113 Prescriptions............................. 114 6.5 Discussion................................ 115 References................................... 118 7 Clinical Case 7: Patient with Severe Obesity....... 121 7.1 Clinical Case Presentation................... 121 Family History............................ 121 Clinical History........................... 122 Physical Examination...................... 122 Haematological Profile..................... 122 Blood Pressure Profile..................... 123 12 -Lead Electrocardiogram................. 123 Current Treatment........................ 125 Diagnosis................................ 126 Global Cardiovascular Risk Stratification..... 127 Treatment Evaluation...................... 127 Prescriptions............................. 127 7.2 Follow-Up (Visit 1) at 6 Weeks............... 128 Physical Examination...................... 128 Blood Pressure Profile..................... 128 Haematological Profile..................... 128 Current Treatment........................ 128 or Associated Clinical Conditions............ 129 Diagnosis................................ 129 Global Cardiovascular Risk Stratification..... 130 Current Treatment........................ 130 Treatment Evaluation...................... 131 Prescriptions............................. 131
Contents xvii 7.3 Follow-Up (Visit 2) at 3 Months............. 131 Physical Examination...................... 131 Blood Pressure Profile..................... 131 Surgical Consultancy....................... 132 Current Treatment........................ 132 Treatment Evaluation...................... 132 Prescriptions............................. 132 7.4 Follow-Up (Visit 3) at 6 Months............. 133 Physical Examination...................... 133 Blood Pressure Profile..................... 133 Haematological Profile..................... 133 Current Treatment........................ 134 Treatment Evaluation...................... 134 Prescriptions............................. 134 7.5 Discussion................................ 134 References................................... 136 8 Clinical Case 8: Patient with Essential Hypertension and Previous Stroke............................ 139 8.1 Clinical Case Presentation................... 139 Family History............................ 139 Clinical History........................... 140 Physical Examination...................... 140 Haematological Profile..................... 140 Blood Pressure Profile..................... 141 12 -Lead Electrocardiogram................. 141 Current Treatment........................ 141 Diagnosis................................ 142 Global Cardiovascular Risk Stratification..... 146 Treatment Evaluation...................... 146 Prescriptions............................. 146 8.2 Follow-Up (Visit 1) at 4 Weeks............... 147 Physical Examination...................... 147 Blood Pressure Profile..................... 147 Haematological Profile..................... 147 Current Treatment........................ 147 or Associated Clinical Conditions............ 148
xviii Contents Diagnosis................................ 148 Global Cardiovascular Risk Stratification..... 149 Treatment Evaluation...................... 149 Prescriptions............................. 150 8.3 Follow-Up (Visit 2) at 3 Months............. 150 Physical Examination...................... 150 Blood Pressure Profile..................... 150 Haematological Profile..................... 150 Current Treatment........................ 151 Treatment Evaluation...................... 151 Prescriptions............................. 151 8.4 Follow-Up (Visit 3) at 1 Year................ 151 Physical Examination...................... 152 Blood Pressure Profile..................... 152 Haematological Profile..................... 152 Current Treatment........................ 152 or Associated Clinical Conditions............ 153 Treatment Evaluation...................... 153 Prescriptions............................. 153 8.5 Discussion................................ 154 References................................... 156