Poorly controlled hypertension is a significant cardiovascular risk factor that requires effective management. Learn more about how to manage it in this case study of a middle-aged night-shift worker with comorbidities and other risk factors.
Case study – Poorly controlled hypertension in a male night-shift nurse
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- Question 1 of 15
1. Question
1. Why does he have headaches?
View Expert Comment »
- Sleep apnoea should be excluded in overweight persons, especially if they are hypertensive and/or diabetic.
- Question 2 of 15
2. Question
2. What possible causes of erectile dysfunction would you want to exclude before referral to a urologist?
View Expert Comment »
- Erectile dysfunction is common in older diabetic men and is indicative of endothelial dysfunction.
- Atenolol is notorious for this side effect.
- Question 3 of 15
3. Question
3. Why would he have effort intolerance?
View Expert Comment »
- Angina can sometimes present as effort intolerance.
- The patient should undergo a stress ECG.
- Question 4 of 15
4. Question
4. List two abnormalities on his ECG.
View Expert Comment »
- LVH is associated with malignant cardiac arrhythmias, including atrial fibrillation, and sudden cardiac death.
- Inverted T-waves in V5-6 suggest systolic overload, but upright T-waves suggest diastolic overload caused by either aortic incompetence or mitral regurgitation.
- Question 5 of 15
5. Question
5. S4 on cardiac auscultation suggests:
View Expert Comment »
- MS has a loud S1 and loud P2, if severe.
- MR has a soft S1 and S3, if severe.
- Question 6 of 15
6. Question
6. What other tests does he need?
View Expert Comment »
- Every diabetic patient should get a urine dipsticks test, regardless of their diabetes control.
- Special investigations should only be requested if clinically indicated.
- Question 7 of 15
7. Question
7. Could he have ‘white-coat’ hypertension?
View Expert Comment »
- LVH, even if a patient has apparently normal office blood pressure, suggests poor blood pressure control.
- Question 8 of 15
8. Question
8. Which drugs would you consider changing in his regimen?
View Expert Comment »
- In the ASCOT-BPLA trial,1 atenolol and the thiazide diuretic, bendroflumethiazide, precipitated diabetes mellitus and were associated with increased cardiovascular and overall mortality. Atenolol aggravates his erectile dysfunction. HCTZ increases uric acid levels.
- Every type 2 diabetic should be on a statin (maximum tolerated dose: starting at 20mg nocte) and aiming for LDL<3mmol/l.
- Question 9 of 15
9. Question
What investigations should then be performed in this patient?
His 24-hour ambulatory blood pressure measurement (ABPM) shows a mean blood pressure of 140/90mmHg and high blood pressure spikes when he is sleeping. His HbA1c is 10% and he has 2+ proteinuria.
9. Why would his blood pressure be high during sleeping?
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- This patient should be referred for a sleep study to exclude OSA.
- Blood pressure medications should be taken at night by people who sleep at night and probably conversely for night-shift workers.2
- Question 10 of 15
10. Question
10. His mean ABPM:
View Expert Comment »
- An average daytime ABPM of less than 135mmHg systolic and 85mmHg diastolic is generally considered normal, but lower levels are being advocated in high-risk groups, such as diabetic patients, in whom levels less than 130/80mmHg are considered optimal.
- Increased ABPM values are associated with poor cardiovascular outcomes.
- Question 11 of 15
11. Question
11. HbA1c
View Expert Comment »
- Weight loss, exercise and decreased carbohydrate intake lower HbA1c.
- The patient has cardiac abnormalities and current SEMDSA guidelines recommend aiming for an HbA1c of around 7%.
- Question 12 of 15
12. Question
12. The proteinuria in our patient reflects:
View Expert Comment »
- Diabetic proteinuria reflects microvascular damage and predicts poor cardiovascular outcomes.
- Question 13 of 15
13. Question
Expert comment and therapy introduced
The patient should be started on an ACE-inhibitor (perindopril) and calcium channel blocker (amlodipine), preferably as single-pill combination (SPC) therapy. Start at the lowest dose of the combination to reduce side effects. Thiazide-like diuretics (e.g. indapamide) are metabolically neutral and do not influence lipid levels. Long-acting diuretics are preferred for effective blood pressure lowering. Indapamide provides 24-hour blood pressure lowering compared to HCTZ, which only gives eight hours of cover. There is also no renoprotection, as well as no stroke and total mortality risk reduction, with HCTZ.3
Next visit
- Three months after changing to combination therapy (perindopril/amlodipine), the patient’s blood pressure remains elevated (150/95mmHg)
13. You will do the following:
View Expert Comment »
- SPC can be increased to 10/5mg or 10/10mg daily.
- Alert the patient to a possible increased cough incidence (3.9% or less than 1 in 20 with perindopril users compared to more than 10% with enalapril). This happens because of an increased level of bradykinin, which is beneficial for vascular endothelial health.
- ARBs have less reported cough, but not a zero-cough incidence.
- Question 14 of 15
14. Question
14. During the last visit the patient was started on 20mg daily simvastatin as per medical aid formulary. His latest LDL reading is 3.2mmol/l and his HDL is 0.8mmol/l; triglycerides are 6mmol/l.
View Expert Comment »
- Those at high-risk of vasculopathy should have an LDL<1.8mmol/l.
- Consider using rosuvastatin, which increases HDL and lowers LDL.
- Question 15 of 15
15. Question
15. The patient’s BMI remains 30kg/m2, despite occasional stair-climbing at work. You will recommend the following:
View Expert Comment »
- Cardio-exercise reduces weight and improves blood pressure.
- The BMI is too low for referral for gastric bypass surgery.
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