CME INDIA Case Presentation by Dr Prattay Guha Sarkar, DM, Cardiology, Assistant Professor of Cardiology at Rajendra Institute of Medical Sciences (RIMS), Ranchi.

CME INDIA Case Study

Case:

• 65year aged, BMI-32, female, presented with complains of occipital headache, giddiness, no LOC
• At admission BP was 210/100
• She was admitted in ICU and started on antihpertensive medications
• Gradually her medications were escalated

Further Course:

• In spite of all these medications BP continued to be high
• Home 180/100
• Office 200/110
• ABPM 24 hr 180/110
• ABPM Night 170/90
• HB 12.1, UREA 43, CREAT 1.3, NA 133, K 4.1, TSH 3.1, URINE VMA Normal, LFT Normal
• Bilateral renal arteries Normal
• Calculated eGFR 60 ML/MIN/M2

Medications:

1. Telmisartan 80
2. Cilnidipine 20
3. Eplerenone 25
4. Torsemide 40
5. Metoprolol 100
6. Clonidine 0.3
7. Minoxidil 10
8. Metolazone 2.5

ECG:

48 hours Holter evaluation did not reveal complete heart block or av dissociation during giddiness

She was asked to monitor k, every 3 days as gfr was 60 and she was being given telmisartan 80 + eplerenone 25

2 weeks later she comes back with SOB and LOC

• BP 210/100
• PR 30 / MIN
• K 6.9
• UREA 52, CREAT 1.4

• Potassium correction given
• She was put on temporary pacing
• Rhythm did not improve on day 2
• Urine out was >100ml/hr
• K on day 2 4.2
• Dual chamber pacemaker implanted

Now, what is the twist in this case, why BP not being controlled, even after optimal use of multiple anti-hypertensives?

History solved the mystery…

History reassess from partner H/O Day Time Somnolence or Snoring or Apneic Spells during sleep sought.

What it reveals?

• All denied, but we went ahead with sleep study in view of refractory hypertension
• In house sleep study revealed severe OSA (Obstructive Sleep Apnea)

• Spo2 as low as 75% was documented
• She was started cpap @ 12 cm h20
• 1 month later we stated tapering meds after BP got better controlled
• At 2 months, she was controlled on telmisartan 80 chlorthalidone 12.5
• She continues to be on permanent pacemaker

Summary of the Case:

CME INDIA Learning Points:

• Obstructive sleep apnea (OSA) is a prevalent sleep disorder as is hypertension (HTN) in the 21st century with the rising incidence of obesity.
• The severity of obstructive sleep apnea syndrome (OSAS) is classified based on the apnea-hypopnea index (number of apneic/hypopneic episodes per hour): 5–15, mild; 15–30, moderate; 30 or more, severe.
• Numerous studies have shown a strong association of OSA with cardiovascular morbidity and mortality. There is overwhelming evidence supporting the relationship between OSA and hypertension (HTN).
• The pathophysiology of HTN in OSA is complex and dependent on various factors such as sympathetic tone, renin-angiotensin-aldosterone system, endothelial dysfunction, and altered baroreceptor reflexes.
• The treatment of OSA is multifactorial ranging from CPAP to oral appliances to lifestyle modifications to antihypertensive drugs.
• OSA and HTN both need prompt diagnosis and treatment to help address the growing cardiovascular morbidity and mortality due to these two entities. (Volume 2017 |Article ID 1848375 | https://doi.org/10.1155/2017/1848375)

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